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Candela et al. Vessel Plus 2018;2:28 I http://dx.doi.org/10.20517/2574-1209.2018.31 Page 5 of 9
depressed cardiac function which is the main factor of hemodynamic instability.
Conversion from TAVR to open heart surgery was infrequently occurring in 2.5% of the LAS group and 2.9%
of the GA group, without any significant difference between the groups.

The main reasons for conversion from LAS to GA were vascular and procedural complications,
hypotension, respiratory complications and insufficient patient compliance or patient discomfort.

The meta-analysis did not reveal a significant difference between the groups in the rate complications
such as major and minor vascular complications, major and life-threatening bleeding, acute kidney injury,
myocardial infarctions and stroke.

Only three studies reported a slightly lower frequency of pneumonia in LAS group, but the difference between
the two groups did not reach statistical significance. It is possible to speculate that this tendency reflects minor
risk of ventilator associated pneumonia (VAP), however is not possible to better analyze this aspect because
too small number of articles reported this outcome. In this review an important difference between the two
groups was highlighted: the length of hospital stay was significantly shorter in the LAS group (MD - 1.49 days)
and the length of intensive care unit (ICU) stay was found to be shorter for patients in the LAS group (MD -
0.47 days). Since the rate of periprocedural complications is similar in both groups, such result is probably
due to the time needed for the transfer of ventilated patients to the ICU, where extubation can occur with
[28]
some delay after the procedure .

[47]
As reported by Gauthier et al. ICU admission may be related with a nosocomial infection, with a
lower risk of infectious complications for patients who received LAS for TAVR, by avoiding bladder
catheterization, central venous catheter insertion and mechanical ventilation.

Another difference between the two groups was a higher rate of pacemaker (PMK) implantations in the
patients who underwent LAS for TAVR occurring in 17.5% of patients compared with 12.8% of the GA
group.

A third-degree atrioventricular block is a frequent periprocedural complication requiring a PMK. This
result may be due to increased patient movement during valve positioning because of discomfort or poor
patient compliance. In some case has been also reported an anxiogenic effect due to decreased cerebral
[37]
blood flow during rapid ventricular pacing . Furthermore, the use of GA eases precise valve positioning
thanks to a short interruption of mechanical ventilation and patient immobility.

DISCUSSION
Analyzing international literature, it appears clear that both anesthesiologic techniques GA and LAS are
safe and none of them influence negatively the patient outcome.

From many studies a new trend towards minimally invasive anesthesia for TAVR has emerged, especially
regarding the TF approach which is the most used technique for TAVR. The choice of anesthetic
management generally depends on the patient’s clinical profile and the procedural technical characteristics,
but a center’s experience and internal organization also play an important role in the decision-making.
When a TAVR program starts, many operators might choose to perform the procedure with GA because
of the uncertainty of a new procedure, initial low volume, operator’s learning curve and the possible
[48]
complications more frequent in centers with low volume of TAVR . As the learning curve of the operators
reaches a new plateau and the techniques of TAVR evolve, the procedure time becomes shorter and the
[48]
complications decrease; this needs around two years of continuous activity or 50 consecutive cases .
Others revealed a learning curve with an improvement in complications rate, after the initial 86 cases using