What are the recommendations for anesthesia in patients post-Transcatheter Aortic Valve Replacement (TAVR)?

From the Guidelines

Anesthesia management for patients post-Transcatheter Aortic Valve Replacement (TAVR) should prioritize early extubation, hemodynamic stability, and meticulous monitoring, as recommended by the most recent guidelines 1. The goal of anesthesia management in these patients is to minimize complications and ensure a smooth recovery.

• Key considerations include:
  • Early extubation and mobilization to reduce the risk of respiratory and thromboembolic complications
  • Hemodynamic stability, with careful management of blood pressure and heart rate
  • Meticulous monitoring for potential complications, such as bleeding, arrhythmias, and conduction abnormalities
  • Multimodal pain management to minimize opioid use and prevent respiratory depression
• According to the 2017 ACC expert consensus decision pathway for TAVR 1, immediate post-procedure management should include waking from sedation, post-procedure monitoring, pain management, early mobilization, and discharge planning.
• The choice of anesthesia technique, whether general or regional, should be individualized based on patient factors and the specific procedure being performed, with consideration of the potential benefits and risks of each approach 1.
• Anticoagulation management is also crucial, with aspirin typically continued perioperatively and other anticoagulants managed based on procedure bleeding risk, as recommended by the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1.
• Overall, a comprehensive and multidisciplinary approach to anesthesia management is essential for optimizing outcomes in patients undergoing TAVR, with a focus on minimizing morbidity, mortality, and improving quality of life.

From the Research

Anesthesia in Patients Post-TAVR

• The current guidelines for anesthesia in patients post-Transcatheter Aortic Valve Replacement (TAVR) are not well-established, but several studies have investigated the use of antiplatelet therapy in these patients 2, 3, 4, 5, 6.
• The studies suggest that single antiplatelet therapy (SAPT) may be associated with a lower risk of bleeding and mortality compared to dual antiplatelet therapy (DAPT) 3, 4, 5, 6.
• A systematic review and meta-analysis found that SAPT was associated with a lower risk of major or life-threatening bleeding and all-cause mortality compared to DAPT 4.
• Another study found that clopidogrel monotherapy was associated with a lower incidence of cardiovascular death compared to aspirin monotherapy during the 2-year follow-up after TAVR 2.
• A network meta-analysis found that single antiplatelet therapy with aspirin had lower bleeding without increasing stroke or death when compared with either 3- or 6-month DAPT 5.
• A systematic review and meta-analysis suggested that aspirin alone could decrease the risk of bleeding and was not associated with higher risk of mortality, stroke, or myocardial infarction compared with DAPT 6.

Recommendations for Anesthesia

• Based on the available evidence, it is recommended that patients post-TAVR receive single antiplatelet therapy with aspirin or clopidogrel, rather than DAPT 2, 3, 4, 5, 6.
• The choice of antiplatelet therapy should be individualized based on the patient's risk factors and medical history 2, 3, 4, 5, 6.
• Further studies are needed to establish the optimal anesthesia strategy for patients post-TAVR 2, 3, 4, 5, 6.