What are the perioperative cardiac risks and medication management recommendations for a patient with a history of aortic valve replacement (AVR), coronary artery disease (CAD), atrial fibrillation (Afib), hypertension (HTN), hyperlipidemia (HLD), pulmonary embolism (PE), and obstructive sleep apnea (OSA) undergoing a dental extraction?

Perioperative Cardiac Risk Assessment and Anticoagulation Management for Dental Extraction

Based on the patient's cardiac history and current status, this patient is at low risk for perioperative cardiac complications during dental extraction, and anticoagulation therapy with aspirin can be safely interrupted. The management should focus on minimizing bleeding risk while ensuring adequate protection against thrombotic events.

Patient Risk Assessment

• The patient has a history of aortic valve stenosis status post transcatheter aortic valve replacement (TAVR) in 2020, coronary artery disease (CAD), atrial fibrillation with pacemaker, hypertension, hyperlipidemia, pulmonary embolism, and obstructive sleep apnea 1
• Current cardiac function is relatively preserved with an ejection fraction of 62% on recent LEXI study (01/2025) and 50-55% on echocardiogram (02/2023) 1
• The bioprosthetic aortic valve shows no regurgitation on recent echocardiogram 1
• Dental extraction is considered a low-risk procedure for cardiac complications 1

Anticoagulation Management

Recommendations for Aspirin Interruption:

• Aspirin can be safely discontinued for dental extraction as indicated in the form 2, 3
• For patients with coronary artery disease and prior TAVR, temporary interruption of aspirin for minor procedures like dental extraction carries minimal risk when the procedure itself has low bleeding risk 4, 2
• Restart aspirin as soon as approved by the surgeon to minimize thrombotic risk, especially important given the patient's history of CAD and TAVR 2

Rationale:

• The 2024 AHA/ACC guidelines support temporary interruption of antiplatelet therapy for procedures with low bleeding risk in stable cardiac patients 1
• For patients with bioprosthetic valves beyond the initial 3-month period post-implantation (this patient is 4+ years post-TAVR), the thrombotic risk during brief antiplatelet interruption is relatively low 1, 3

Endocarditis Prophylaxis

• SBE (subacute bacterial endocarditis) prophylaxis IS recommended for this patient 1
• Patients with prosthetic cardiac valves, including transcatheter-implanted prostheses, are at higher risk for infective endocarditis and should receive antibiotic prophylaxis for dental procedures that involve manipulation of gingival tissue 1

Perioperative Medication Management

• Continue usual cardiac medications on the morning of the procedure 1, 4
• Statins should be continued perioperatively as they reduce the risk of major adverse cardiac events 1
• Beta-blockers, if the patient is on them, should be continued to maintain hemodynamic stability 1

Special Considerations

• Obstructive sleep apnea (OSA) increases risk for postoperative cardiac complications, but the risk is minimized in this low-risk dental procedure 1
• If the patient uses CPAP for OSA management, they should resume use as soon as possible after the procedure 1
• The patient's preserved ejection fraction (62%) is reassuring for low perioperative risk 1
• Monitor for any signs of cardiac decompensation, though this is unlikely given the minor nature of the procedure and the patient's stable cardiac status 1, 4

Follow-up Recommendations

• Resume aspirin as soon as hemostasis is achieved and approved by the dental surgeon 2
• Monitor for any unusual bleeding or cardiac symptoms in the immediate post-procedure period 4
• No additional cardiac testing is required before or after this low-risk procedure given the patient's stable cardiac status 1