What is the next step in managing a 77-year-old male with a history of aortic stenosis, status post Transcatheter Aortic Valve Replacement (TAVR), Atrial Fibrillation (A-fib) on Xarelto (Rivaroxaban), Hypertension (HTN), and Hyperlipidemia (HLD), who presents with ongoing dizziness at rest and during activities despite recent valve replacement and normal prosthetic valve function?

Management of Persistent Dizziness Post-TAVR

The next step is a comprehensive medication review focusing on antihypertensive and anticoagulant dosing, followed by orthostatic vital signs assessment and evaluation for coronary ischemia, as the prosthetic valve function is confirmed normal and arrhythmias have been excluded. 1

Systematic Approach to Post-TAVR Dizziness

Immediate Medication Assessment

Review and optimize all cardiovascular medications, particularly antihypertensives and anticoagulation therapy. 1

• The patient is on Xarelto for atrial fibrillation, which is appropriate per ACC guidelines for TAVR patients with chronic AF 2
• However, elderly TAVR patients have high bleeding risk and medication side effects can cause persistent dizziness 1, 2
• Assess for overmedication with antihypertensives causing orthostatic hypotension, which is common in this population 1
• Consider whether blood pressure medications need dose reduction given the improved cardiac output post-TAVR 1

Orthostatic Vital Signs and Hemodynamic Evaluation

Perform orthostatic blood pressure measurements at rest and with activity to identify positional hypotension. 3, 4

• The patient's dizziness occurs both at rest and with activities (winding garden hose), suggesting a hemodynamic rather than positional cause 4
• Post-TAVR patients often have altered hemodynamics that require medication adjustment 1
• Document blood pressure and heart rate supine, sitting, and standing at 1 and 3 minutes 3

Coronary Artery Disease Evaluation

Evaluate for coronary ischemia as a cause of symptoms, particularly given the exertional component. 1

• ACC guidelines recommend evaluation for coronary disease if symptoms are present post-TAVR 1
• Coronary artery disease is present in 40-75% of TAVR patients 1
• The dizziness with activity (winding garden hose) raises concern for exertional ischemia 1
• Consider stress testing or coronary angiography if clinical suspicion is high 1

Neurological Assessment

Perform targeted neurological examination to exclude posterior circulation ischemia or vestibular causes. 3, 4

• The timing pattern (both rest and activity) suggests this is not benign paroxysmal positional vertigo 4
• Perform HINTS examination (head-impulse, nystagmus, test of skew) if vertigo is a component 3, 4
• Consider vascular imaging for extracranial carotid or vertebral stenosis given the recurrent syncope history 1

Echocardiographic Re-evaluation

While recent echo showed normal valve function, consider repeat assessment if clinical deterioration continues. 1, 2

• ACC guidelines recommend echocardiography for any change in clinical status post-TAVR 2
• Evaluate for paravalvular leak, which may not have been initially apparent 1
• Assess left ventricular function and stroke volume index, as low flow (<35 mL/m²) predicts poor outcomes regardless of ejection fraction 1
• The improved but still low-normal LVEF (50-55%) may indicate persistent cardiac dysfunction 1

Critical Pitfalls to Avoid

Do not attribute all symptoms to the recent TAVR procedure without excluding other serious causes. 1

• The loop recorder excluded arrhythmias, but this does not rule out other cardiovascular causes 1
• Recurrent syncope in an elderly patient warrants aggressive investigation despite normal valve function 1
• Multiple anticoagulant/antiplatelet therapies increase bleeding risk and may cause occult bleeding leading to anemia and dizziness 1, 2

Do not overlook medication-induced hypotension as the most common reversible cause in this population. 1, 3

• TAVR patients are elderly with multiple comorbidities requiring frequent medication adjustments 1
• The combination of anticoagulation (Xarelto), antihypertensives, and potentially other cardiac medications creates high risk for adverse effects 1, 2

Monitoring Strategy

Increase frequency of follow-up given the change in clinical status. 1

• ACC guidelines recommend increased follow-up frequency for any change in clinical status post-TAVR 1
• The patient is within the critical first 30-day post-TAVR period requiring close monitoring by the implanting team 1
• Schedule weekly visits until symptoms resolve or a definitive cause is identified 1