Prophylactic bi-level non-invasive positive pressure ventilation during monitored anesthesia care for transfemoral TAVI in a morbidly obese patient with obstructive sleep apnea: a case report

Transcatheter aortic valve implantation (TAVI) is increasingly performed under monitored anesthesia care (MAC); however, its use in patients with morbid obesity and obstructive sleep apnea (OSA) remains challenging because of the risk of hypoventilation and airway compromise. Prophylactic planned intraoperative non-invasive ventilation may offer a strategy to safely extend MAC to this high-risk population, but evidence in this setting remains scarce.

We report a case of transfemoral TAVI successfully performed under MAC in a 67-year-old morbidly obese patient with severe OSA using bi-level non-invasive positive pressure ventilation (NIPPV), dexmedetomidine-based sedation, and regional analgesia. NIPPV was applied perioperatively to support spontaneous ventilation and optimize oxygenation, allowing the completion of the procedure without airway intervention or conversion to general anesthesia. The patient had an uneventful recovery and was discharged on the fourth postoperative day.

This case demonstrates that prophylactic bilevel non-invasive positive pressure ventilation (NIPPV) can facilitate the safe use of monitored anesthesia care during TAVI in selected high-risk patients, supporting a physiology-driven strategy to maintain spontaneous ventilation while avoiding general anesthesia.