Background: As transcatheter aortic valve implantation (TAVI) has become a standard treatment for severe aortic stenosis, the optimal anesthetic strategy remains debated. In addition to anesthesia choice, institutional experience may influence procedural efficiency and outcomes; however, their interplay remains unclear. This study aimed to evaluate the association between anesthetic strategy and outcomes after elective transfemoral TAVI and to assess whether these associations are modified by institutional experience.

Methods: In this retrospective observational study, consecutive patients undergoing elective transfemoral TAVI at a high-volume tertiary center between 2020 and 2025 were analyzed. To reduce selection bias, inverse probability weighting with double-robust outcome modeling was applied. The primary outcome was intensive care unit (ICU) stay duration, and in-hospital mortality was evaluated as a secondary outcome. Institutional experience was modeled as chronological case sequence, with an interaction term to assess effect modification.

Results: A total of 852 patients were included. After weighting, baseline characteristics were well balanced between conscious sedation (CS) and general anesthesia (GA) groups. General anesthesia utilization decreased from 71% in 2020 to 13% in 2025. Conscious sedation was associated with shorter ICU stay compared with GA (21.0 vs. 23.0 hours; P < .001). In adjusted analysis, GA remained independently associated with longer ICU stay (rate ratios = 1.46, P < .001, 95% CI: 1.28-1.66). Anesthetic strategy was not associated with in-hospital mortality (OR = 1.14, P = .667, 95% CI: 0.62-2.10), and no significant interaction with case sequence was observed.

Conclusion: Conscious sedation was associated with shorter ICU stay, while no significant differences were observed in mortality outcomes.