Anaesthesia support for transcatheter heart valve interventions: a narrative review

INTRODUCTION: There have been few other areas of medical practice in the last two decades that have evolved at the same pace as transcatheter heart valve interventions. As well as providing peri-operative care, anaesthetists are core members of 'Heart Teams', who plan the care of and manage patients with valvular heart disease. This review aims to summarise core information on these procedures for anaesthetists. METHODS: We conducted a literature review to identify highly cited or high Altmetric scoring articles published in the last five years on the peri-operative management of patients undergoing transcatheter aortic, mitral, pulmonary and tricuspid valve interventions. RESULTS: There was little contemporary published evidence comparing or recommending anaesthetic techniques and describing their effect on peri-operative outcomes. Instead, there is a wealth of evidence on outcomes in specific patient risk groups undergoing transcatheter procedures. However, these trials focussed mainly on mortality and complications, received substantial industry funding and pooled adverse outcomes as a composite using frequentist non-inferiority methods. Most real-world patients would likely be excluded from these trials and clinicians therefore should apply evidence, expertise and local experience to make risk/benefit judgements for individual patients referred to the Heart Team. Knowledge of the issues around diagnosis, patient selection, procedural steps and device design characteristics are arguably of more importance to the anaesthetist than the specifics of techniques for local anaesthesia infiltration, conscious sedation and general anaesthesia, which are transferrable skills for all adult anaesthetists. DISCUSSION: There is a need for new peri-operative research with a focus on patient-centred metrics, rather than complication composites and mortality outcomes. Clinically, there is increasing focus on patient-centred treatment, timing of interventions and a team-based approach with greater emphasis placed on comorbidities and their aggressive management.