Anaesthesia for TAVI and structural heart interventions

[1]

Why this is examined / the one-line answer

TAVI/TAVR is the structural-heart list case: critical aortic stenosis (AS) physiology plus cath-lab/hybrid-lab anaesthesia plus device crises. PARTNER established TAVI for inoperable severe AS; practice now spans intermediate and lower surgical risk — exams still start with AS goals, lab CRM, and whether you can convert when the day goes wrong.[2]

One-liner: I keep afterload up and coronary perfusion pressure, use sedation or GA with a conversion plan, monitor invasively, and prepare for vascular catastrophe, annular rupture, coronary obstruction, severe PVL, and complete heart block. [1]

Preoperative assessment

Lesion and anatomy

• Severe AS metrics: mean gradient, aortic valve area, LVEF, low-flow low-gradient work-up if needed.
• Coronary height/anatomy (obstruction risk), annular sizing, calcification.
• Access: transfemoral (TF) vs alternative (transapical, transaortic, transcaval, subclavian).
• Conduction disease (bundle branch block → post-TAVI PPM risk).
• Frailty, cognitive state, ability to lie flat and cooperate for sedation.
• Airway, GORD/aspiration risk, severe lung disease, CKD (contrast), anticoagulation status.
• Heart-team decision: cardiology, cardiac anaesthesia, cardiac surgery backup. [1]

Functional and comorbidity map

Coronary disease, mitral disease, pulmonary hypertension, porcelain aorta (why TAVI chosen), previous CABG, peripheral vascular disease (access bleeding risk). [1]

Applied physiology — AS goals that save lives

Maintain: [1]

• Preload (avoid abrupt venodilatation).
• Sinus rhythm and avoid tachycardia (diastolic filling time for LV and coronary perfusion).
• SVR / afterload — coronary perfusion pressure roughly tracks aortic diastolic pressure minus LVEDP; pure vasodilatation is dangerous in fixed obstruction.[3]

Avoid: deep propofol dumps, untreated tachyarrhythmia, hypovolaemia under anaesthesia, and treating pure AS like vasodilated sepsis without diagnosis. [1]

Rapid ventricular pacing: reduces stroke volume for stable valve deployment; expect brief profound hypotension — team choreography matters (pace → deploy → recover). [1]

Anaesthetic goals

1. Haemodynamic stability through induction and deployment.
2. Still patient and safe airway plan for imaging/deployment.
3. Immediate crisis capability (vascular, annular, coronary, conduction).
4. Conditions for TOE when needed.
5. Safe recovery and conduction surveillance. [1]

Technique: GA vs conscious sedation

Evidence line examiners want

SOLVE-TAVI randomised local anaesthesia with conscious sedation versus general anaesthesia for TF-TAVR and found comparable outcomes for its primary combined endpoint — supporting that both techniques can be safe in appropriate patients with experienced teams.[1]

How you choose (not ideology)

Always have conversion drugs, airway kit, defibrillation/pacing, and surgical backup ready before sheaths.[3]

Monitoring and equipment

• Arterial pressure (radial ± femoral sheath arterial pressure).
• Large IV access; vasopressor infusion drawn before GA induction in critical AS.
• Defibrillator pads on; temporary pacing capability.
• ACT monitoring if large sheaths/heparin protocol.
• TOE probe if GA/needed; TTE available in lab culture.
• Difficult airway kit; emergency drugs; blood available.
• Hybrid lab CRM: clear roles for vascular catastrophe and sternotomy/ECMO pathways. [1]

Intraoperative management — sequence thinking

1. Team brief: access route, sedation vs GA, conversion triggers, PPM risk, surgical backup location.
2. Gentle GA induction if chosen (opioid, low-dose induction agent, early vasopressor). Sedation: titrate, maintain spontaneous ventilation and communication.
3. Heparin per protocol for large sheaths.
4. Wire, balloon valvuloplasty (if used), rapid pace, deploy — verbal closed-loop communication.
5. Post-deployment: gradients, PVL, LV function, ECG (new LBBB/CHB), coronary signs, access site.
6. Reverse anticoagulation per protocol when safe; vascular closure vigilance. [1]

Crisis pivots (table you should own)

Postoperative plan

Monitored bed; serial ECGs for delayed heart block; vascular observations (limb ischaemia/bleed); renal function after contrast; analgesia sparing in frail elderly; restart antithrombotics per cardiology; watch for access-site pseudoaneurysm. [1]

Special populations

• Bicuspid valves / valve-in-valve: anatomy-specific risks; still AS goals.
• Alternative access (transapical/transaortic): usually GA; thoracotomy pain and surgical bleeding.
• Cardiogenic shock TAVI: ICU-level case; mechanical support may already be in play.
• Concomitant PCI: dual antiplatelet implications later for any regional plans.
• Other structural procedures (TEER, left atrial appendage, PFO): different lesion physiology — do not automatise AS rules to MR clips without thought. [1]

SAQ answer scaffold

A 82-year-old with severe AS for TF-TAVI. Discuss anaesthetic technique and intraoperative crises. [1]

1. AS goals (3): preload, SVR, sinus, avoid tachycardia.[3]
2. Sedation vs GA (3): SOLVE-TAVI equivalence signal; individualise; conversion ready.[1]
3. Monitoring (2): arterial line, pacing/defib, vasopressors, airway kit.
4. Deployment sequence (2): pace–deploy–recover communication.
5. Crises (4): vascular bleed, annular rupture/tamponade, coronary obstruction, CHB, severe PVL.
6. Postop (2): conduction and vascular surveillance.

Viva stem bank and model phrases

Stem 1: “Sedation or GA?”
Model: “Both can be safe; SOLVE-TAVI supports comparable outcomes for TF-TAVR. I individualise on airway, cooperation, access, and TOE need, and I prepare conversion before starting.”[1]

Stem 2: “How do you induce critical AS?”
Model: “Maintain SVR and coronary perfusion pressure, avoid tachycardia and deep vasodilation, and have a dilute vasopressor infusion running early.” [1]

Stem 3: “Sudden PEA after deployment?”
Model: “Tamponade/annular rupture, severe AR/PVL, coronary obstruction, or pacing failure — simultaneous echo and surgical call while resuscitating.” [1]

Stem 4: “Why did PARTNER matter?”
Model: “It established TAVI for patients with severe AS who could not undergo surgery — the historical foundation of the field.”[2]

Stem 5: “Access-site hypotension with stable ECG?”
Model: “Occult retroperitoneal or iliofemoral bleeding under drapes until proven otherwise — examine, call vascular/interventional rescue, resuscitate.” [1]

Stem 6: “New LBBB post-TAVI?”
Model: “Conduction trauma risk — monitored bed, pacing capability, lower threshold for permanent pacing discussion with cardiology.” [1]

Stem 7: “Can they go to a normal ward in 2 hours?”
Model: “Only if stable access site, no conduction concern, and unit pathway allows — many need extended monitoring overnight.” [1]

Common traps

• Deep propofol dump in critical AS
• No conversion plan
• Ignoring access bleeding under drapes
• Missing heart block
• Treating AS like pure afterload-reduction heart failure
• Starting without surgical backup culture
• Sedation without airway rescue readiness [1]

[1] [1] [1]

Hybrid-lab CRM specifics

Noise, radiation, and divided attention make CRM harder than main theatre. Use closed-loop communication for pace-deploy-recover. Pre-agree who leads ACLS if PEA occurs under the C-arm. Keep a clear path to the airway at the head despite drapes. Know where the sternotomy set and perfusionist are — "somewhere in the building" is not a plan. [1]

Post-deployment checklist (verbal)

ECG rhythm, pacing threshold if temporary wire, invasive pressure, echo/fluoro PVL, coronary signs, access site, ACT/heparin plan, destination (CCU/ICU), family update. This two-minute ritual catches delayed heart block and silent groin haematoma. [1]

Examiner mental map

1. AS haemodynamic goals.
2. Sedation vs GA with SOLVE-TAVI one-liner.
3. Monitoring and lab CRM.
4. Deployment sequence and pacing.
5. Crisis table (VASC).
6. Postop conduction and vascular care. [1]

If you sound like a hybrid-lab team member rather than a textbook of aortic stenosis alone, you pass. [1]

References

1. [1]Thiele H, Kurz T, Feistritzer HJ, et al. General Versus Local Anesthesia With Conscious Sedation in Transcatheter Aortic Valve Implantation: The Randomized SOLVE-TAVI Trial Circulation, 2020.PMID 32819145
2. [2]Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery N Engl J Med, 2010.PMID 20961243
3. [3]Mayr NP, Michel J, Bleiziffer S, et al. Sedation or general anesthesia for transcatheter aortic valve implantation (TAVI) J Thorac Dis, 2015.PMID 26543597