What is the recommended management for a patient status post Transcatheter Aortic Valve Replacement (TAVR)?

Post-TAVR Management Protocol

Patients post-TAVR require a structured follow-up regimen with dual antiplatelet therapy, regular cardiac monitoring, and coordinated care between specialists to optimize mortality and morbidity outcomes. 1

Immediate Post-Procedure Management

Access Site Care and Early Mobilization

• Monitor access site carefully for bleeding, hematoma, or pseudoaneurysm formation 1
• Provide appropriate pain management tailored to the elderly population 1
• Mobilize patient as soon as access site allows, typically within 24 hours 1
• Encourage early extubation if general anesthesia was used 1

Hemodynamic Monitoring

• Maintain careful monitoring of vital signs, telemetry, and volume status 1
• Prevent postoperative hypertension, especially in transapical TAVR patients, to reduce bleeding risk 1
• Ensure adequate hydration to minimize renal failure risk 1

Pre-Discharge Assessment

• Obtain pre-discharge echocardiogram to assess valve function 1
• Perform pre-discharge ECG to establish new baseline 1
• Resume pre-operative medications as appropriate 1
• Arrange physical and occupational therapy assessment 1

Long-Term Management Protocol

Follow-Up Schedule

• TAVR team evaluation at 30 days 1
• Primary cardiologist follow-up at 6 months and then annually 1
• Primary care physician or geriatrician follow-up at 3 months and then as needed 1
• More frequent follow-up for patients with changes in symptoms or transient conduction abnormalities 1

Antithrombotic Therapy

• Aspirin 75-100 mg daily lifelong 1
• Clopidogrel 75 mg daily for 3-6 months 1
• For patients at risk of atrial fibrillation or venous thromboembolism, consider warfarin with target INR 2.0-2.5 1

Cardiac Monitoring

• Echocardiography at 30 days and then annually (if needed) 1
• ECG at 30 days and annually 1
• Consider 24-hour ECG monitoring if bradycardia is present 1
• Monitor for conduction disturbances, which remain the most frequent complication post-TAVR 2

Management of Comorbidities

• Actively manage concurrent cardiac conditions 1:
  • Coronary artery disease
  • Hypertension
  • Heart failure
  • Arrhythmias (especially atrial fibrillation)

Laboratory Monitoring

• Regular assessment of blood counts, metabolic panel, and renal function 1
• Assess pulmonary, renal, GI, and neurological function annually or as needed 1

Complication Surveillance and Management

Valve-Related Complications

• Monitor for structural valve degeneration, which can occur years after implantation 3
• Watch for signs of paravalvular leak or central regurgitation 4
• Be alert for rare but serious complications like valve embolization or migration 5

Vascular Complications

• Assess for vascular access site complications, which remain a major concern 6
• Early detection and management of bleeding complications is crucial 5, 6

Endocarditis Prevention

• Encourage optimal dental hygiene 1
• Provide antibiotic prophylaxis according to AHA/ACC guidelines 1

Pitfalls and Caveats

• Readmission Risk: Post-TAVR patients have >40% readmission rate in the first year, often for non-cardiac causes including respiratory problems, infections, and bleeding events 1

• Conduction Abnormalities: These remain the most frequent complication of TAVR and require vigilant monitoring 2

• Coordination Gap: Failure to coordinate care between TAVR team, cardiologist, and primary care can lead to missed complications or medication errors 1

• Medication Management: Ensure proper antiplatelet/anticoagulant balance based on patient's specific risk factors 1

• Valve Durability: Long-term durability of transcatheter valves is not yet fully established, requiring ongoing surveillance 1