Anesthesia Type and Outcomes After Transfemoral TAVI: A Time-Sensitive Comparative Analysis

Background: The optimal anesthesia strategy for transfemoral transcatheter aortic valve implantation (TAVI) remains uncertain. We evaluated the impact of local anesthesia, conscious sedation, and general anesthesia on early and long-term outcomes after TAVI. Methods: This single-center cohort included 401 patients undergoing transfemoral TAVI with local anesthesia (LA, n = 77), conscious sedation (CS, n = 147), or general anesthesia (GA, n = 177). Outcomes were assessed using hierarchical win-ratio analysis prioritizing mortality over major adverse cardiovascular and cerebrovascular events (MACCE), supported by Kaplan-Meier and restricted mean survival time analyses. Sensitivity analyses using inverse probability of treatment weighting (IPTW) were performed to account for baseline differences between groups. Results: Baseline comorbidities were broadly comparable, although GA patients had higher-risk anatomical and procedural features. In unadjusted win-ratio analyses, LA showed a significant advantage over GA at 0-6 months (win ratio [WR] 1.79; 95% CI 1.10-2.93; p = 0.020). After multivariable adjustment, LA remained superior to GA at 6-12 and 12-24 months (adjusted WR 1.67 and 1.56, both p < 0.05). One-year mortality differed significantly among groups (p = 0.012). RMST analysis demonstrated a cumulative survival advantage for LA versus GA, reaching 6.6 months at 60 months. MACCE-free survival was largely comparable across strategies. However, in IPTW-weighted analyses, anesthesia type was not independently associated with mortality or MACCE. Conclusions: Minimally invasive anesthesia strategies were associated with more favorable early survival patterns after transfemoral TAVI in primary analyses. However, after adjustment for baseline differences using IPTW, anesthesia type was not independently associated with mortality or MACCE. These findings suggest that apparent outcome differences may partly reflect underlying patient risk profiles rather than a purely causal effect of anesthesia strategy.