How to manage a patient with prosthetic aortic valve stenosis after TAVR, presenting with heart failure, hematuria, and volume overload?

Management of Prosthetic Aortic Valve Stenosis After TAVR

For a 76-year-old patient with prosthetic aortic valve stenosis after TAVR presenting with heart failure symptoms, hematuria, dizziness, and volume overload, valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is the recommended treatment approach.

Initial Assessment

1. Confirm prosthetic valve stenosis:

   • Transthoracic echocardiography (TTE) to measure transprosthetic gradients, calculate effective orifice area, and assess Doppler velocity index 1
   • Transesophageal echocardiography (TOE) if TTE is inconclusive 1

2. Evaluate heart failure severity:

   • Current symptoms suggest advanced heart failure with volume overload
   • Multiple admissions for heart failure indicate progressive deterioration
   • Hematuria may suggest severe right heart failure with hepatic congestion

3. Assess comorbidities:

   • Age (76) and multiple heart failure admissions indicate higher surgical risk
   • Evaluate for contributing factors to heart failure such as:
     • Cardiac amyloidosis
     • Myocardial fibrosis
     • Multivalvular disease
     • Pulmonary hypertension
     • Coronary artery disease
     • Atrial fibrillation 2

Treatment Algorithm

Step 1: Stabilize Heart Failure

• Diuresis to manage volume overload
• Optimize heart failure medications per standard guidelines
• Monitor renal function closely given hematuria

Step 2: Definitive Management of Prosthetic Valve Stenosis

Valve-in-Valve TAVR (ViV-TAVR) is the preferred approach for this patient with:

• Advanced age (76 years)
• Multiple heart failure admissions
• High surgical risk profile 3

The 2012 ACCF/AATS/SCAI/STS expert consensus document specifically recommends that "with chronic severe AR with symptoms of heart failure, surgical AVR may be considered if the patient is a surgical candidate and surgical risk is acceptable. Other options include placement of a second TAVR within the leaking prosthesis ('valve-in-valve')" 3.

Step 3: Post-Procedure Management

After ViV-TAVR:

• Antithrombotic therapy:

  • Aspirin 75-100 mg daily lifelong
  • Clopidogrel 75 mg daily for 3-6 months 3
  • Consider anticoagulation if patient has atrial fibrillation 3

• Follow-up schedule:

  • First follow-up within 30 days
  • Echocardiography at 30 days and then annually 3
  • ECG at 30 days and annually 3

Important Considerations

Expected Outcomes

• ViV-TAVR has shown improvement in valve area from 0.87±0.31 cm² to 1.38±0.55 cm² and reduction in mean gradients from 36±18 mmHg to 18±11 mmHg 4
• However, postprocedural gradients may remain higher than in native valve TAVR 4

Potential Complications

• Higher postprocedural gradients are associated with:
  • Small surgical valves (internal diameter ≤19 mm)
  • Stented surgical valves 4
• Risk of prosthesis-patient mismatch
• Conduction disturbances requiring pacemaker
• Paravalvular leaks 2

Cautions

1. Avoid multiple anticoagulant therapies if possible to reduce bleeding risk 3
2. Monitor for recurrent heart failure as it is the most common cause of rehospitalization after TAVR 2
3. Be aware that urgent/emergent TAVR carries higher risk of complications compared to elective procedures 5
4. Consider that quality of life improvement may be less significant in urgent cases 5

Conclusion

Given this patient's age, multiple heart failure admissions, and current presentation with volume overload, ViV-TAVR represents the most appropriate management strategy for prosthetic aortic valve stenosis after previous TAVR. This approach offers the best balance of effectiveness and safety compared to high-risk surgical valve replacement.