From the Guidelines
TAVR can be performed on this patient, but they are at increased risk for respiratory complications due to their mixed lung disease. The pulmonary function test results indicate that this patient has both moderate restrictive and moderate obstructive lung disease without bronchodilator response. This means the patient has limitations in both lung expansion (restrictive component) and airflow (obstructive component). The normal FEV1/FVC ratio with reduced flows suggests a complex mixed pattern. The DLCO (diffusing capacity) is reduced but normal when adjusted for alveolar ventilation, indicating that gas exchange is relatively preserved despite the mechanical limitations.
To optimize outcomes in the preoperative period, I recommend:
- Optimizing current inhaler therapy with both long-acting bronchodilators (such as tiotropium 18mcg daily and formoterol 12mcg twice daily) 1
- A short course of systemic steroids (prednisone 20mg daily for 5-7 days) to reduce any inflammatory component
- Pulmonary rehabilitation with breathing exercises and incentive spirometry training for 2-3 weeks if time permits
- Smoking cessation if applicable
- Treatment of any respiratory infections
- Consideration of preoperative pulmonary consultation to establish a post-operative respiratory care plan
The mixed lung disease increases the risk of post-TAVR respiratory failure, prolonged ventilation, and pneumonia. However, TAVR is generally better tolerated than surgical valve replacement in patients with compromised pulmonary function, as it avoids general anesthesia and intubation in many cases, as supported by the 2017 AHA/ACC guideline for the management of patients with valvular heart disease 1. Close monitoring of respiratory status and early mobilization post-procedure will be essential for this patient. According to the 2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement, TAVR is a suitable option for patients with severe symptomatic AS who are at high risk for surgical AVR 1.
From the Research
Patient Condition
- The patient has a combination of moderate restrictive lung disease and moderate obstructive lung disease without response to bronchodilators (BD) 2, 3.
- The FEV1/FVC ratio is normal, indicating no significant obstructive pattern 4.
- The patient is unable to perform plethysmography maneuvers due to physical condition, making it challenging to assess lung function accurately.
- The DLCO is reduced, but when compared per unit alveolar ventilation, it is normal, suggesting that the gas exchange is not severely impaired 5.
TAVR Procedure
- There is no direct evidence to suggest that the patient's lung condition would preclude a Transcatheter Aortic Valve Replacement (TAVR) procedure 6.
- However, the patient's moderate obstructive and restrictive lung disease may increase the risk of respiratory complications during and after the procedure.
Preoperative Optimization
- Preoperative optimization of the patient's lung function is crucial to reduce the risk of respiratory complications 6, 4.
- This may include:
- Inhaler therapy to manage obstructive lung disease 4.
- Pulmonary rehabilitation to improve lung function and overall physical condition 4.
- Treatment of comorbidities, such as congestive heart failure, to reduce the risk of complications 3.
- Administration of influenza and pneumococcal immunizations to prevent respiratory infections 4.
- Close monitoring of the patient's lung function and overall condition is essential to ensure that they are optimized for the TAVR procedure.