Is it safe to proceed with left total knee replacement after a recent Transcatheter Aortic Valve Replacement (TAVR) procedure?

Timing of Total Knee Replacement After TAVR

Total knee replacement should be delayed until at least 3 months after TAVR to minimize the risk of complications, as the Heart Valve Team is responsible for care during the first 30 days post-TAVR when procedural complications are most likely to occur. 1

Risk Assessment for Non-Cardiac Surgery After TAVR

The timing of non-cardiac surgery after TAVR is critical for patient safety. The guidelines provide important considerations:

Early Post-TAVR Period (0-30 days)

• This is the highest risk period when most TAVR-related complications occur 1
• The Heart Valve Team maintains primary responsibility during this period 1
• Potential complications include:
  • Heart block (may be delayed up to 30 days) 1, 2
  • Device migration/malposition 1
  • Paravalvular regurgitation 1
  • Vascular access complications 1

Intermediate Period (30-90 days)

• Transition period where care transfers from the Heart Valve Team to the primary cardiologist 1
• Antithrombotic therapy is still critical (dual antiplatelet therapy with clopidogrel and aspirin) 1
• First follow-up echocardiography typically occurs at 30 days 1, 2

Safe Period (>90 days)

• Most TAVR-related complications have manifested by this time
• Research shows that non-cardiac surgeries can be performed safely after this period 3

Specific Recommendations for Total Knee Replacement

Antithrombotic Management

• The patient is likely on dual antiplatelet therapy (aspirin 75-100mg daily plus clopidogrel 75mg daily) for 3-6 months post-TAVR 1
• Interruption of this therapy for surgery within the first 3 months carries significant risk

Cardiac Monitoring Requirements

• Continuous cardiac monitoring is essential if surgery is performed within the first 30 days due to risk of delayed heart block 1, 2
• ECG monitoring should be considered even beyond 30 days, especially if the patient received a self-expanding valve (CoreValve) which has higher rates of conduction abnormalities 2

Hemodynamic Stability

• TAVR significantly improves hemodynamics for non-cardiac surgery by reducing transaortic pressure gradients 3
• However, the full benefit is best realized after complete recovery and stabilization of the TAVR

Implementation Plan

1. Delay surgery until after 3 months post-TAVR (after September 20,2025)

2. Obtain cardiology clearance with:

   • Recent echocardiography to confirm proper valve function
   • ECG to evaluate for conduction abnormalities
   • Assessment of antithrombotic therapy needs

3. If surgery must proceed earlier:

   • Continuous cardiac monitoring is mandatory
   • Cardiology consultation for perioperative management
   • Consider maintaining aspirin while temporarily discontinuing clopidogrel if beyond 30 days

Common Pitfalls to Avoid

• Premature discontinuation of dual antiplatelet therapy: This increases risk of valve thrombosis in the early post-TAVR period 1, 2
• Inadequate cardiac monitoring: Heart block can occur up to 30 days post-procedure 1
• Failure to recognize valve-specific risks: Self-expanding valves have higher rates of delayed conduction abnormalities than balloon-expandable valves 2
• Underestimating bleeding risk: TAVR patients often have complex antithrombotic regimens that require careful perioperative management 1

The evidence strongly supports delaying elective orthopedic procedures until at least 3 months after TAVR to optimize patient outcomes and minimize complications.