What essential information should a nurse know when caring for an older adult (>65 years) patient with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR)?

Essential Nursing Care for TAVR Patients

As a nurse caring for TAVR patients, your immediate priorities are vigilant monitoring for vascular access complications, cardiac conduction abnormalities requiring pacemaker placement, and neurological changes, while facilitating early mobilization and coordinating complex discharge planning for this elderly, comorbid population. 1

Immediate Post-Procedure Management (First 24-72 Hours)

Critical Monitoring Parameters

Vascular Access Site Surveillance:

• Monitor the groin or thoracic access site continuously for bleeding, hematoma formation, or pseudoaneurysm development
• Perform ultrasound evaluation if you suspect pseudoaneurysm formation
• Assess distal pulses and perfusion regularly to detect vascular complications early 1

Neurological Assessment:

• Conduct frequent neurological checks to identify stroke, which is a significant TAVR complication
• Monitor mental status closely, particularly in elderly patients who may develop delirium
• Document any focal deficits or changes in consciousness immediately 1

Cardiac Monitoring:

• Maintain continuous telemetry monitoring per your hospital protocol
• Watch specifically for new conduction abnormalities and heart block—these patients frequently require permanent pacemaker placement
• Monitor vital signs closely, including volume status and intake/output 1

Laboratory Surveillance:

• Obtain and monitor CBC for bleeding complications
• Check metabolic panel (M6) for electrolyte abnormalities and renal function
• Trending these values helps identify complications before they become critical 1

Pain Management and Mobilization

Pain Control:

• Provide appropriate analgesia, but exercise caution with sedating medications in elderly patients
• Balance pain relief against the risk of delirium and respiratory depression
• Reassess pain frequently and adjust accordingly 1

Early Mobilization Strategy:

• Mobilize patients as soon as the access site permits—typically within hours for transfemoral approach
• Encourage physical activity to prevent deconditioning
• Coordinate with physical and occupational therapy for formal assessment before discharge 1

Pre-Discharge Requirements

Before discharge, ensure completion of:

• Predischarge echocardiogram to assess valve function
• ECG to document baseline rhythm and identify conduction abnormalities
• Physical therapy/occupational therapy evaluation to determine appropriate discharge disposition
• Medication reconciliation—resume preoperative medications that remain appropriate 1

Discharge Medications and Patient Education

Antithrombotic Therapy Protocol

Standard regimen for patients without other indications:

• Aspirin 75-100 mg daily lifelong (this is non-negotiable)
• Clopidogrel 75 mg daily for 3-6 months post-procedure
• For patients with atrial fibrillation or venous thromboembolism risk, consider warfarin with target INR 2.0-2.5 instead 1

Critical Patient Instructions

Endocarditis Prophylaxis:

• Educate patients about the importance of optimal dental hygiene
• Ensure they understand when antibiotic prophylaxis is required per AHA/ACC guidelines
• Provide written instructions about dental care 1

Warning Signs Requiring Immediate Medical Attention:

• New or worsening shortness of breath
• Chest pain
• Syncope or near-syncope (may indicate heart block)
• Access site complications (bleeding, swelling, pain)
• Neurological symptoms
• Fever (potential endocarditis)

Long-Term Follow-Up Coordination

Structured Follow-Up Schedule

TAVR team visit at 30 days (mandatory):

• Echocardiogram to assess valve function
• ECG to evaluate for conduction abnormalities
• Consider 24-hour Holter monitoring if bradycardia is present 1

Primary cardiologist at 6 months, then annually:

• Annual echocardiography if clinically indicated
• Annual ECG
• Ongoing management of concurrent cardiac conditions (coronary disease, hypertension, heart failure, arrhythmias) 1

Primary care physician or geriatrician at 3 months and as needed:

• Monitor blood counts, metabolic panel, and renal function
• Assess pulmonary, renal, GI, and neurological function
• Manage the extensive comorbidities these patients typically have 1

Special Considerations for the TAVR Population

Understanding Your Patient Population

These patients are fundamentally different from typical cardiac surgery patients:

• TAVR patients are typically older (often >80 years) with substantial comorbidity burden
• Over 40% will be readmitted within the first year, predominantly for non-cardiac causes (respiratory issues, infections, falls)
• Functional dependence and frailty are common—these factors predict outcomes better than chronological age alone 1, 2, 3, 4

Common Pitfalls to Avoid

Don't assume age alone determines outcomes:

• A 90-year-old with minimal comorbidities may do better than a 70-year-old with multiple conditions
• Frailty assessment (using tools like the Essential Frailty Toolset) is more predictive than age
• Patients requiring frequent post-acute rehabilitation before TAVR have particularly poor outcomes 2, 3, 4

Don't overlook discharge planning complexity:

• Start discharge planning before the procedure
• Many patients will require skilled nursing facility placement or home health services
• Coordinate with case management early—these patients have complex social and medical needs 1

Don't forget cardiac rehabilitation:

• Cardiac rehabilitation significantly improves functional capacity and quality of life post-TAVR
• Unfortunately, few elderly patients are referred—advocate for your patients
• Women are referred even less frequently despite higher mortality rates 5

Key Nursing Responsibilities

You are the frontline for complication detection:

• Most serious complications (vascular injury, stroke, heart block) manifest in the immediate post-procedure period
• Your vigilant monitoring and early recognition can prevent mortality and morbidity
• Document thoroughly and communicate concerns immediately to the TAVR team

You are the coordinator of complex care:

• These patients require integration across multiple specialties
• Ensure seamless communication between the TAVR team, primary cardiologist, and primary care physician
• Outcomes depend as much on management of non-cardiac conditions as on the valve itself 1

You are the patient educator:

• Ensure patients and families understand medication regimens, particularly anticoagulation
• Teach recognition of warning signs
• Emphasize the importance of follow-up appointments and dental care
• Provide written instructions—elderly patients may have difficulty retaining verbal information