TAVI for Residents: Evidence, Rapid Pacing and Sedation

Everybody asks how you anaesthetise a patient for a TAVI. The answer takes about four seconds: it's lidocaine into the groin. For more than 95% of our patients that is very nearly it — transfemoral, local anaesthetic, a little procedural sedation from a nurse, and they never meet an anaesthetist at all. Which raises the obvious question: why do a whole episode on it? Because the fact that the anaesthetic is trivial does not make this a low-risk procedure — and our value here has almost nothing to do with giving an anaesthetic. That's the thesis of the episode. Please note: the drugs and doses discussed are Wythenshawe-specific local practice. Take the principles, and check your own guidelines. We start with scale. TAVI is arguably the biggest disruptor in medical practice of the last twenty years — from perhaps forty cases in the UK in the early years to several thousand annually now. While anaesthesia debated video laryngoscopy and TIVA, the cardiologists took a brand new procedure and generated randomised trial after randomised trial. Then diagnosis done properly. How you derive the aortic valve area on TOE using the continuity equation — and why three separate measurements plus a geometric assumption, with the LVOT diameter squared, is a lot of places to be wrong. Hence the velocity ratio, the dimensionless index that cancels the LVOT area entirely and doesn't need the ventricle to generate a big gradient. Plus why gated CT with a calcium score now answers anatomy, feasibility, access and sizing in a single scan. We cover who gets TAVI over surgery — and the point that surprises people, which is that almost anybody can have a surgical AVR, while TAVI is the fussy one, ruled out by access and anatomy. Then the evidence arc from PARTNER through NOTION, SURTAVI, PARTNER 3 and Evolut Low Risk, a defence of non-inferiority as exactly the right question here, and two honest problems: the patients we actually treat would never have met the trial inclusion criteria, and the trials are funded by the people selling the valves. Plus the warning signal for younger patients, where surgical explant of a TAVI valve carries a high mortality. Finally the practical half: minimalist TAVI and the fall in mortality from over 5% to under 2%; why rapid ventricular pacing at over 200 for a few seconds is needed and how to avoid it altogether with a self-expanding valve; the complications, including a roughly one-in-five permanent pacemaker rate; what the published reports into a struggling centre actually identify (selection, expertise and governance — never the anaesthetic technique); conversion planning and a patient who dissected in the cath lab and did well anyway; the anaesthetic and sedation techniques when they are needed; the principles for the severe aortic stenosis patient, ending on patience; and the rest of the cath lab, including MitraClip. Chapters (00:00) Cold open — "it's lidocaine into the groin" (01:10) Why a trivial anaesthetic doesn't mean a low-risk procedure (02:10) TAVI as the biggest disruption in twenty years (03:40) Grading the valve: the continuity equation and its errors (05:30) Why the velocity ratio is the better number (06:40) The gated CT that answers everything at once (07:40) Who gets TAVI — and why TAVI is the fussy option (09:10) PARTNER to Evolut: the evidence arc (11:00) Two problems: external validity, and who funds the trials (12:40) The warning signal for younger patients (13:50) Minimalist TAVI, and the fall in mortality (15:20) Rapid ventricular pacing — and when to avoid it (16:40) Complications, and the one-in-five pacemaker (17:50) When it goes wrong: selection, expertise, governance (18:40) Conversion planning, and a patient who surprised us (19:40) Anaesthesia, sedation, and the principle of patience (20:40) MitraClip and the rest of the cath lab (21:20) Wrap-up Key takeaways For over 95% of patients TAVI is local anaesthetic and light sedation — and that does not make it low risk The continuity equation needs three measurements and a geometric assumption; the velocity ratio needs neither Gated CT with a calcium score answers grading, anatomy, feasibility and access in one scan Almost anyone can have a surgical AVR; TAVI is the fussy option, ruled out by access and anatomy Non-inferiority is the right question, because the recovery benefits are so large The evidence is excellent but generated in patients unlike ours — and funded by the valve manufacturers Surgical explant of a TAVI valve carries a high mortality, which matters for younger patients Minimalist TAVI has taken mortality from over 5% to under 2%, with fewer steps and less stroke Rapid pacing stops the ventricle fighting the balloon; if they won't tolerate it, use a self-expanding valve Roughly one in five need a permanent pacemaker — a genuine complication, though the rate is falling Plan the conversion before you start: pericardial window, bypass, or neither For the aortic stenosis patient: minimise demand, optimise supply — and above all, be patient References / further reading Charlesworth M et al. Anaesthesia support for transcatheter heart valve interventions: a narrative review. Anaesthesia 2025 Leon MB et al. PARTNER: TAVI in patients who cannot undergo surgery. NEJM 2010 Thyregod HGH et al. NOTION: TAVI versus surgery in lower-risk patients. J Am Coll Cardiol 2015 Reardon MJ et al. SURTAVI: TAVI versus surgery in intermediate-risk patients. NEJM 2017 Mack MJ et al. PARTNER 3: TAVI with a balloon-expandable valve in low-risk patients. NEJM 2019 Popma JJ et al. Evolut Low Risk: TAVI with a self-expanding valve in low-risk patients. NEJM 2019 Fukuhara S et al. Surgical explantation of transcatheter aortic bioprostheses. J Thorac Cardiovasc Surg 2021 Vahanian A et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2021 This podcast is for medical education for healthcare professionals. It is not clinical advice. All drugs and doses discussed reflect local Wythenshawe practice at the time of recording — always follow your own centre's guidelines and current local policy.