Background: Transcatheter aortic valve implantation (TAVI) can be performed in local anesthesia or conscious sedation (LACS) or general anesthesia (GA). Potential benefits of LACS, as faster procedures and shorter hospital stays, need to be balanced with safety.

Objectives: To report the utilization of each anesthesiological strategy in a large population undergoing TAVI and to assess the influence of LACS versus GA on early and mid-term mortality.

Methods: 16543 patients from the German Aortic Valve Registry undergoing transfemoral TAVI from 2011 to 2014 were analyzed. To correct for an inherent selection bias and baseline differences propensity-matched analyses were performed taking into account variables with known prognostic impact or showing significant univariate differences between both groups (Figure 1 - A)

Results: LACS was used in 49% (8121/16543) of patients. From 2011 to 2013, the proportion of procedures performed in LACS decreased with increasing numbers of procedures and then remained stable at 46% (p for the trend <0.001). There was an inverse relationship in the utilization of LACS with center experience with 66% of patients undergoing TAVI in LACS in high volume centers. Independent predictors to undergo TAVI in LACS were younger age, lower STS score and ASA class, presence of a permanent pacemaker, pulmonary hypertension, lower mean transaortic gradients as well as year of procedure and increasing center experience.  Overall, procedural success was achieved in 97.6%. There was no difference in paravalvular leakage (II+) between LACS and GA in the entire (5% vs. 4.8%, p=0.76) or in the matched population (3.9% vs. 4.9%, p=0.13). In-hospital, LACS was associated with lower rates of low-output syndrome, respiratory failure, delirium, cardiopulmonary resuscitation and death. The risk of prolonged ICU stay (≥3 days) was significantly reduced with LACS (odds ratio (OR) 0.82, 95% confidence interval (CI) [0.73-0.92], p=0.001). 30-day mortality was lower with LACS in the entire (3.5% vs. 4.9%, OR 0.70 95% CI [0.58-0.85], p<0.001) and in the matched population (2.8% vs. 4.6%, OR 0.6 95%CI [0.44-0.8], p=0.001). However, no differences in 1-year mortality between both groups in the entire (16.5% vs. 16.9%, hazard ratio (HR) 0.93 9% CI [0.85-1.02], p=0.140) and in the propensity-matched population (14.1% vs. 15.5%, HR 0.90 95% CI [0.78-1.03], p=0.130) were observed (Figure 1- B).

Conclusions: The present study underlines the safety and efficacy of LACS in TAVI with a less complicated post-procedural course and lower early mortality and confirms logistic benefits justifying the broad application by experienced teams.