Local anesthesia alone versus with sedation for transcatheter aortic valve implantation: a systematic review and meta-analysis

BACKGROUND: As minimalist transcatheter aortic valve implantation (TAVI) programs continue to expand globally, significant practice variation persists in anesthetic strategy. This meta-analysis directly compares the safety and efficacy of local anesthesia alone (LA) versus local anesthesia with sedation (LAS) for TAVI. METHODS: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception through September 2025. Primary outcomes included all-cause mortality, stroke, acute kidney injury (AKI), and ≥ moderate paravalvular regurgitation (PVR). Secondary outcomes encompassed procedural complications and efficiency metrics. Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CIs) were calculated using random- or fixed-effects models. RESULTS: Seven studies (one randomized controlled trial, six observational) with 2,990 patients (LA: n = 1,229; LAS: n = 1,761) were included. We found no significant differences between LA and LAS in all-cause mortality (RR 0.67, 95% CI 0.35-1.29, p = 0.23), stroke (RR 0.77, 95% CI 0.37-1.62, p = 0.49), AKI (RR 0.67, 95% CI 0.26-1.73, p = 0.41), or PVR (RR 1.03, 95% CI 0.63-1.69, p = 0.91). Rates of vascular complications, pacemaker implantation, and major bleeding were also comparable. Procedural efficiency metrics, including procedure time (MD 2.76 min, 95% CI -2.70-8.21, p = 0.32) and hospital length of stay (MD -0.48 days, 95% CI -1.16-0.19, p = 0.16), did not differ significantly between groups. CONCLUSIONS: In patients undergoing transfemoral TAVI, a minimalist approach using LA alone is non-inferior to LAS regarding short-term safety, efficacy, and procedural efficiency. These findings suggest that anesthetic strategy may be individualized based on patient-specific factors and operator experience while maintaining comparable clinical outcomes. REGISTRATION: PROSPERO CRD420251146705.