What are the post-transcatheter aortic valve replacement (TAVR) management recommendations?

Post-TAVR Management Recommendations

Based on current ACC guidelines, all patients post-TAVR should receive aspirin 75-100 mg daily lifelong, with clopidogrel 75 mg daily added for 3-6 months in patients without an indication for anticoagulation. 1, 2

Antithrombotic Therapy

Standard Regimen (No Anticoagulation Indication)

• Aspirin 75-100 mg daily indefinitely 1, 2
• Clopidogrel 75 mg daily for 3-6 months post-procedure 1, 2
• Recent evidence suggests single antiplatelet therapy (aspirin alone) reduces bleeding risk without increasing thrombotic events, stroke, or mortality compared to dual antiplatelet therapy 3, 4
• If choosing single antiplatelet therapy, clopidogrel monotherapy may be superior to aspirin monotherapy, showing lower cardiovascular mortality at 2 years 5

Patients with Atrial Fibrillation or Other Anticoagulation Indications

• Anticoagulation per AF guidelines for prosthetic heart valves is mandatory 1
• Vitamin K antagonist therapy (INR 2.0-2.5) should be considered, particularly in the first 3 months 1, 2
• Continuation of aspirin with anticoagulation is reasonable, but avoid adding clopidogrel due to excessive bleeding risk with triple therapy 1, 6

Special Consideration: Valve Thrombosis Risk

• Vitamin K antagonist therapy may be considered in patients at risk of valve thrombosis in the first 3 months, as anticoagulation (not antiplatelet therapy) effectively prevents and treats bioprosthetic valve thrombosis 6

Follow-Up Schedule

Structured Surveillance Timeline

• TAVR team evaluation at 30 days post-procedure 2
• Primary cardiologist follow-up at 6 months, then annually 2
• Primary care physician or geriatrician at 3 months, then as needed for management of non-cardiac comorbidities 2

Diagnostic Monitoring

Echocardiography Protocol

• Pre-discharge echocardiogram to establish baseline including transvalvular velocity, mean gradient, valve area, and paravalvular regurgitation assessment 1
• Repeat echocardiography at 30 days, then annually to monitor for complications, assess valve durability (stenosis, regurgitation, leaflet calcification/thrombosis), and guide medical therapy for concurrent conditions 1, 2
• Key parameters to assess: LV size and function, regional wall motion, mitral valve function, pulmonary pressures, and right ventricular function 1

Electrocardiographic Monitoring

• ECG at 30 days and annually 2
• Consider 24-hour Holter monitoring if bradycardia present 2
• Routine ECG assessment is critical as conduction abnormalities and heart block can occur late after TAVR, particularly with self-expanding valves, potentially requiring pacemaker implantation beyond 30 days 1
• Periodic monitoring for asymptomatic atrial fibrillation is recommended 1

Management of Cardiac Comorbidities

Common Post-TAVR Cardiac Conditions

• Optimize coronary artery disease management 2
• Control hypertension aggressively 2
• Implement guideline-directed medical therapy for heart failure/LV dysfunction 1, 2
• Manage mitral valve disease and pulmonary hypertension as indicated by serial echocardiography 1
• Referral back to the Heart Valve Team is appropriate when prosthetic valve dysfunction is suspected or if additional structural interventions are needed 1

Endocarditis Prevention

Infection Prophylaxis Strategy

• Standard antibiotic prophylaxis per AHA/ACC guidelines for all prosthetic valves 1, 2
• Encourage optimal dental hygiene and regular dental visits for routine cleaning and care 1, 2
• Early prosthetic valve endocarditis rates range from 0.3% to 3.4% per patient-year, making prevention critical 1

Stroke Risk Management

Cerebrovascular Monitoring

• Clinical stroke rates are 3-5% at 30 days, though subclinical microembolism may be more common 1
• The long-term effects of microemboli remain unclear, warranting vigilance for neurological symptoms 1

Rehabilitation and Functional Recovery

Physical Activity Optimization

• Early mobilization post-procedure is crucial, especially in elderly patients with multiple comorbidities 2
• Promote physical activity appropriate to patient condition 2
• Consider formal cardiac rehabilitation programs for deconditioned patients 2

Critical Pitfalls to Avoid

• Do not underestimate bleeding risk with dual antiplatelet therapy—readmission rates exceed 40% in the first year, often from non-cardiac causes including bleeding 2
• Do not use triple therapy (anticoagulation + dual antiplatelet) except in extraordinary circumstances due to prohibitive bleeding risk 1
• Do not neglect late conduction abnormalities—pacemaker needs can emerge beyond the initial 30-day period 1
• Do not assume valve durability is indefinite—annual surveillance for structural valve deterioration is essential as long-term durability data remain limited 1