Transcatheter aortic valve implantation (TAVI) is a relatively new method to treat patients with severe symptomatic aortic stenosis (AS). TAVI represents a minimally invasive alternative to the current standard treatment for AS, which is surgical aortic valve replacement (AVR).
A recent study published in the Journal of Thoracic Disease, explores the practical aspects for those who deal with TAVI implantation.  Here, the authors describe two main steps required to guide the procedure and achieve the desired benefits with minimal complications.
Firstly, assessing patients’ eligibility for TAVI is of utmost importance. Identification of high or prohibitive surgical risk for the patient should rely on the clinical judgment of a Heart Team in conjunction with information from the patient and family, comorbidities and surgical risk scores.
The paper also guides clinicians through the steps required to successfully select the vascular approach, highlighting the value of imaging tests and comparing the findings, advantages and indications of multidetector computed tomography, magnetic resonance and angiography, depending on the vascular segment considered and the renal function of a given candidate. Other imaging modalities are also discussed, including: transthoracic/ transaesophageal echocardiography, intravascular ultrasound, transcarotid/transcranial ultrasonography, cerebrovascular magnetic resonance angiogram.
Secondly, the paper provides a framework with key issues and considerations in performing the procedure through different access routes: (1) transfemoral, (2) transaortic, (3) trans-subclavian (4) transapical, and (5) other approaches (transcarotid, transcaval, and antegrade aortic).
Procedural details include anaesthesia administration, assessment of optimal fluoroscopic views for device deployment, anticoagulation, possible annular predilation, valve delivery and deployment, and post-deployment valve assessment. Vascular complications and other difficulties might be minimised with the aid of these recommendations.
Regarding anaesthetic approaches, in 2014 a subanalysis of the French Aortic National CoreValve and Edwards 2 Registry compared the outcomes in patients who underwent transfermoral TAVI under general anaesthetic (GA) and local anaesthetic (LA).  In this subanalysis 2326 patients were analysed. It was found that the outcomes (device success and cumulative 30-day survival rates) were similar in both groups, however postprocedural aortic regurgitation was more common in LA than GA (19.1 versus 15.0%, P = 0.015).
Both anaesthetic approaches have their pros and cons. General anaesthetic allows full control over respiration and ensures patient immobility, but it also carries risks such as haemodynamic instability, which may not be tolerated well in elderly patients. Local anaesthetic is considered more comfortable in elderly patients, and being awake during the procedure enables the rapid detection of stroke and other vascular complications. However, there is an increased incidence of postprocedural aortic regurgitation. 
However, TAVI is one of the most rapidly expanding technologies in medical care today, and as our population ages, we will see increasing numbers of people with severe AS. It is important to provide guidance on optimal use of this treatment, as this much-welcomed paper clearly intends to do so. 
This cardionote was prepared by Dr Amelia Carro-Hevia (Spain) and published simultaneously on Cardio Debate and CardioMaster websites, as part of an ongoing collaboration between the two educational platforms. For more information on Cardiomaster please visit www.cardiomaster.net
- Pascual I, Carro A, Avanzas P, Hernández-Vaquero D, Díaz R, Rozado J, Lorca R, Martín M, Silva J, Morís C. Vascular approaches for transcatheter aortic valve implantation. J Thorac Dis. 2017;9(Suppl 6):S478-S487
- Oguri A, Yamamoto M, Mouillet G, et al. Clinical outcomes and safety of transfermoral aortic valve implantation under general versus local anesthesia. Subanalysis of the French Aortic National CoreValve and Edwards 2 Registry. Circulation: Cardiovascular Interventions 2014; 7: 602-10.