General vs. non-general anesthesia for transcatheter aortic valve replacement: A real-world target trial emulation study

BACKGROUND: The optimal anesthetic strategy for transcatheter aortic valve replacement (TAVR) remains debated, with limited real-world data on long-term outcomes and healthcare utilization. METHODS: We conducted a retrospective cohort study using the TriNetX Global Collaborative Network, including adults undergoing TAVR between January 2015 and December 2024. Patients were categorized by anesthetic strategy: general anesthesia (GA) or non-general anesthesia (NGA; regional anesthesia or sedation). A target trial emulation framework with 1:1 propensity score matching was used to balance baseline characteristics. Outcomes at 30, 90, and 365 days included all-cause mortality, major cardiovascular, renal, and respiratory complications, and all-cause hospital readmission. RESULTS: After matching, 3586 patients (1793 per group) were included. All-cause mortality did not differ between GA and NGA at 30, 90, or 365 days. Rates of stroke, myocardial infarction, acute kidney injury, atrial fibrillation, major vascular complications, and respiratory failure were also similar across follow-up intervals. At 365 days, heart failure was nominally higher in the GA group compared with NGA (HR 1.44, 95% CI 1.05-1.99; p = 0.023). NGA was associated with lower all-cause hospital readmission within 30 days post-procedure, with no differences at later follow-up. CONCLUSIONS: In this large real-world analysis, anesthetic strategy during TAVR was not associated with differences in mortality or most major complications through one year. Although heart failure events at 365 days were nominally higher with GA, overall outcomes were largely comparable. NGA was associated with reduced early hospital readmission.