Awake-TAVI: Impact of anesthesia techniques on peri- and postoperative outcomes in TAVI patients

Background Transcatheter aortic valve implantation (TAVI) has been a standard therapy for severe aortic stenosis since 2002, initially performed under general anesthesia. As procedural experience has grown, local anesthesia with or without procedural sedation has gained acceptance, particularly in high-risk patients. However, data comparing short- and long-term outcomes between anesthesia strategies remain limited. The 2021 ESC/EACTS Guidelines recommend individualizing anesthesia selection based on patient comorbidities, anatomical considerations, and procedural complexity, advocating a patient-centered approach. Methods This retrospective cohort study analyzed 225 consecutive TAVI patients treated at our center between January 1 and September 30, 2022. Patients were stratified based on anesthesia protocol into: - Local anesthesia with procedural sedation (LAPS, n=42) - Converted anesthesia (initial LA requiring sedation/general anesthesia, n=77) - Local anesthesia alone (LA, n=106) Intraoperative parameters, including procedure duration and sedation requirements, were compared. Postoperative endpoints included laboratory parameters, echocardiographic data, incidence of delirium, infection, and acute kidney injury. The study was approved by the Heinrich-Heine-Universität ethics committee (Study No. 2023-2489). Results Among the 225 patients, those in the LA group were significantly taller and heavier than those in the LAPS and Converted groups (p=0.031; p=0.042), while age and sex distributions were comparable. NYHA classification differed significantly (p=0.032), with a higher proportion of NYHA III-IV patients in the LA group. Sedation levels varied significantly (p<0.0001), with LAPS patients receiving twice the remifentanil dose of the Converted group. The LA group had a lower incidence of post-procedural delirium (p=0.006) and shorter ICU stays. Hospitalization duration was similar across all groups (mean 7.75 days, p=NS). No significant differences were observed in 30-day MACCE, myocardial infarction, stroke/TIA, or bleeding rates. At one-year follow-up, MACCE incidence was higher in the LA group (p=0.014). Long-term analysis through October 31, 2023, revealed a significant increase in MACCE (p<0.001) and mortality (p=0.012) in the LA group. The higher mortality observed in the LA group was not directly attributed to the TAVI procedure or anesthesia strategy but likely reflects the higher baseline comorbidity burden in this cohort. Conclusion Local anesthesia was associated with short-term benefits, including lower post-procedural delirium rates and comparable hospitalization duration. However, the higher long-term MACCE and mortality rates in the LA group underscore the need for careful patient selection and risk stratification when considering awake TAVI strategies. Prospective, multicenter studies are required to determine the optimal anesthesia approach for TAVI in complex patient populations.