What are the key components of post-Transcatheter Aortic Valve Replacement (TAVR) nursing care?

Post-TAVR Nursing Care

Immediate post-TAVR nursing care should prioritize intensive hemodynamic monitoring, access site surveillance for vascular complications, early mobilization, and vigilant neurological assessment, as these interventions directly impact the high morbidity and mortality risks in this elderly, high-risk population. 1

Immediate Postprocedure Management (First 24-72 Hours)

Hemodynamic Monitoring

• Monitor vital signs continuously per institutional protocol for sedation/anesthesia recovery, including telemetry, blood pressure, heart rate, and oxygen saturation 1
• Assess volume status closely with strict intake and output monitoring to prevent both fluid overload and hypovolemia 1
• Maintain adequate hydration and avoid early diuretic administration to minimize acute kidney injury risk 1
• Monitor for hypotension, which can indicate bleeding, cardiac tamponade, or hemodynamic instability 2

Access Site Management

• Perform meticulous access site monitoring to detect bleeding, hematoma, or pseudoaneurysm formation early 1
• Ensure adequate hemostasis with normal distal blood flow 1
• Use ultrasound of groin site if concern for pseudoaneurysm develops 1
• For transfemoral patients, maintain supine positioning until femoral vascular sheaths are removed and hemostasis achieved 1
• For transapical patients, monitor thoracostomy tube drainage and manage chest tube removal 1

Neurological Assessment

• Conduct frequent neurological assessments to detect stroke early, as major stroke independently predicts prolonged recovery and increased mortality 1, 3
• Monitor mental status continuously during recovery from sedation 1
• Be aware that embolic strokes from calcific emboli are common complications 1

Cardiac Conduction Monitoring

• Monitor continuously for conduction abnormalities and heart block, which can occur up to 30 days post-procedure 1
• Obtain baseline ECG to document any conduction abnormalities 1
• Enhanced surveillance is critical, particularly if patients are discharged early, as complete heart block may be delayed 1

Pain Management and Comfort

• Provide appropriate pain management, especially important in elderly patients with high comorbidity burden 1
• For transapical patients, provide adequate analgesia for thoracotomy incisional pain 1
• Prevent postoperative hypertension, particularly in transapical patients, to decrease bleeding or ventricular rupture risk 1

Early Mobilization

• Mobilize patients as soon as access site allows to prevent deconditioning and complications 1
• Encourage physical activity early in the recovery process 1
• Initiate physical and occupational therapy assessment to determine appropriate post-hospitalization disposition 1

Laboratory Monitoring

• Monitor complete blood count for anemia and thrombocytopenia, which are relatively frequent and associated with mortality and bleeding complications 4
• Check metabolic panel and renal function regularly, as acute kidney injury is a common complication 1, 5
• Assess for blood disorders that may complicate recovery 4

Medication Management

• Review preoperative medications and restart all appropriate medications promptly 1
• Initiate aspirin 75-100 mg daily lifelong 1, 6
• Start clopidogrel 75 mg daily for 3-6 months 1, 6
• Consider warfarin (INR 2.0-2.5) if patient has atrial fibrillation or venous thromboembolism risk 1, 6

Predischarge Preparation

Diagnostic Studies

• Obtain predischarge echocardiogram to establish baseline valve function, including transvalvular velocity, mean gradient, valve area, and paravalvular regurgitation assessment 1, 6
• Perform baseline ECG to document conduction status 1

Discharge Planning

• Initiate structured discharge plan prior to procedure 1
• Schedule TAVR team follow-up at 30 days 1, 6
• Schedule primary cardiologist appointment at 6 months 1, 6
• Schedule primary care physician or geriatrician appointment within 3 months 1, 6
• Provide clear patient instructions on when and how to contact the care team 1
• Educate patient on medication regimen, activity restrictions, and warning signs of complications 1

Early Discharge Considerations

• Early discharge within 72 hours does not increase 30-day mortality, bleeding, pacemaker implantation, or rehospitalization risk in selected transfemoral TAVR patients 1
• Ensure appropriate disposition and outpatient medical care scheduling before discharge 1

Critical Nursing Pitfalls to Avoid

Vascular Complications

• Do not underestimate vascular complication risk—major vascular complications independently predict major bleeding, transfusion, renal failure, and mortality 3
• Women are more prone to vascular complications despite better overall survival 3

Delayed Conduction Abnormalities

• Do not assume conduction is stable after initial monitoring—heart block can be delayed up to 30 days and pacemaker needs can emerge beyond the initial period 1, 6

Readmission Risk Awareness

• Be aware that readmission rates exceed 40% in the first year, with 60% due to non-cardiac causes including respiratory problems, infections, and bleeding events 1, 6
• Cardiac readmissions are most often for arrhythmias or heart failure 1

Anticoagulation Management

• Do not use triple therapy (anticoagulation plus dual antiplatelet therapy) except in extraordinary circumstances due to prohibitive bleeding risk 6
• Avoid adding clopidogrel to patients on anticoagulation plus aspirin 6

Paravalvular Leak Monitoring

• Monitor for moderate to severe paravalvular leak, which significantly decreases survival and requires increased follow-up frequency 1, 3, 5

Ongoing Surveillance Needs

Comorbidity Management

• Coordinate care for concurrent cardiovascular conditions including coronary disease, hypertension, heart failure, and arrhythmias (especially atrial fibrillation) 1, 6
• Assess pulmonary, renal, gastrointestinal, and neurological function regularly 1

Patient Education

• Encourage optimal dental care and hygiene 1, 6
• Educate about antibiotic prophylaxis per AHA/ACC guidelines for endocarditis prevention 1, 6
• Promote cardiac risk factor reduction and healthy lifestyle 1
• Involve patient actively in managing their condition 1