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Page 6 of 9 Candela et al. Vessel Plus 2018;2:28 I http://dx.doi.org/10.20517/2574-1209.2018.31
[49]
the Edwards valve and 40 cases using the CoreValve . Due to this improvement in the procedure time
and complications rate, the care team should be able to perform safely LAS for patients undergoing TAVR.
Although minimal invasive anesthesiologic management is always more widespread, in some clinical
situations could be advantageous provide TAVR under GA. This is particularly true in patients unable to
maintain adequate immobility throughout the procedure. This may include patients with neurological
impairment and patients with advanced heart failure with pulmonary edema that impede to keep supine
position for prolonged periods of time. Even if TEE can used also under sedation, the planned use of TEE
may necessitate GA, because of long time esophageal stimulation. The general opinion is that TEE can help
during valve deployment and in rapid identification of complications; nevertheless, its routine use may not
be justified.

A further clinical situation in with providing GA may be safer than LAS is when patient is expected to be
at high risk for intraprocedural complications because of anatomic conformation.

Prevention of these complications should be based on patient screening and selection by a dedicated “heart
team”. In such cases, the use of multimodality imaging may play an even more important role, with the
aim to evaluate patient suitability for the proposed access site and to select prosthesis size based on aortic
measurement. Preprocedural program is also useful to ensure if proposed device can be safely deployed,
based on device characteristics and the anatomic relationships between the aortic valve and root, left
[50]
ventricle and coronary ostia . As experience suggests, if pre-procedural evaluation estimates that there
might be a mechanical complication, GA is recommended rather than sedation. The same management is
recommended for patient with difficult airway management because, in case of emergency conversion from
LAS to GA, any delay in endotracheal intubation may be unsafe.

Another important consideration in management of patients undergoing TAVR should be considered: over
the last decade, TAVR has emerged to become the preferred alternative for high-risk patients with severe
aortic symptomatic stenosis. Nevertheless, new perspective seems destined to expand indications for TAVI
towards lower risk, younger and asymptomatic populations [51,52] . In such a case, a less invasive strategy,
using LAS instead of GA, seems to be even more appropriate in order to make TAVR procedure even safer,
faster, with fewer risks and to achieve a easier post-operative management.

CONCLUSION
Preoperative anesthesiologic management should be based on the experience of the team, preferring
GA in the initial phases of the program (about 50 cases). Selection of anesthetic technique should be
individualized on the patient’s clinical status, preferring GA in case of difficult airway and in case of
predicted technical difficulty. Instead, patients with advanced respiratory disease or renal impairment or
patients with high risk in developing delirium after GA, should be treated by LAS.

Whether the team provide GA or LAS, the hybrid operating room must be equipped with devices for
managing difficult airways and emergency scenarios. Also, there is an agreement that anesthesiologists
involved in performing TAVR must be part of a “heart team”, who must be confident with anesthesia for
cardiovascular surgery, with mechanical circulatory support, and with TEE.

DECLARATIONS
Authors’ contributions
Concept, drafting, data collection, final approval: Candela C, Di Pumpo A
Critical revision, final approval: Centonze A, Cucciniello F