What are the potential complications and management strategies for patients post Transcatheter Aortic Valve Replacement (TAVR)?

Complications Post-TAVR

Post-TAVR complications require vigilant surveillance and structured management, with the most critical early complications being conduction abnormalities requiring pacemaker implantation, paravalvular regurgitation, vascular access site injuries, stroke, and acute kidney injury—all of which significantly impact both short-term mortality and long-term quality of life. 1, 2

Immediate Post-Procedural Complications (0-3 Days)

Cardiac Conduction Abnormalities and Heart Block

• Complete heart block requiring permanent pacemaker implantation is the most common cardiac complication, occurring more frequently with self-expanding valves (CoreValve). 1
• Pre-existing conduction delays significantly increase pacemaker risk. 1
• Heart block can occur up to 30 days post-procedure, requiring enhanced surveillance even after early discharge. 1
• Obtain baseline ECG immediately post-procedure and monitor continuously with telemetry for at least 48-72 hours. 1
• Consider 24-hour Holter monitoring if bradycardia develops. 1, 3

Paravalvular Regurgitation

• Moderate to severe paravalvular regurgitation must be addressed before leaving the procedure room. 1
• Post-procedural paravalvular regurgitation is associated with adverse outcomes including increased mortality and reduced quality of life. 1, 2
• Adequate balloon aortic valvuloplasty prior to self-expanding valve deployment reduces paravalvular leak risk. 1
• Post-valve dilation with slightly oversized balloon can be performed safely if needed. 1
• Moderate/severe paravalvular leak is independently associated with 37% increased mortality risk at 1 year and 3.2-point reduction in health status scores. 2

Vascular Complications

• Major vascular complications occur significantly more frequently with TAVR compared to surgical AVR (particularly in the first 3 days). 4
• Monitor access site meticulously for bleeding, hematoma, or pseudoaneurysm formation. 1, 5
• Perform ultrasound of groin site if pseudoaneurysm is suspected. 1
• For percutaneous transfemoral access, obtain completion descending aortogram after sheath removal to assess for distal aortic or iliofemoral perforations/dissections. 1
• Large-vessel aortoiliac injury can be managed with covered stent placement in most cases. 1

Stroke

• Stroke is associated with 2.62-fold increased risk of early death (<3 months) and 6.1-point reduction in 1-year health status scores among survivors. 2
• Perform frequent neurological assessments in the immediate post-procedural period. 1, 5

Major Ischemic Stroke Management:

• Consider catheter-based mechanical embolic retrieval for major strokes. 1
• Local rt-PA may be considered, though bleeding risk is very high in this elderly population. 1

Minor Ischemic Stroke Management:

• Treat with aspirin for minor strokes or small infarcts. 1
• If atrial fibrillation is present, initiate oral anticoagulation. 1
• If intracardiac thrombus detected, start heparin followed by oral anticoagulants. 1
• Perform vascular imaging, echocardiography, and Holter monitoring when stable. 1

Acute Kidney Injury

• Stage 3 AKI is associated with 3.43-fold increased risk of early death (<3 months). 2
• Maintain adequate hydration and avoid early diuretic administration to minimize AKI risk. 1, 5
• Monitor intake and output closely. 1, 5
• Acute kidney injury occurs significantly more frequently with surgical AVR than TAVR. 4

Bleeding Complications

• Life-threatening or disabling bleeding is significantly higher with surgical AVR compared to TAVR. 4
• Bleeding complications are independently associated with 83% increased risk of early death (<3 months). 2
• Provide hemodynamic support and blood transfusion as needed. 1
• For transapical approach, prevent postoperative hypertension to decrease bleeding/ventricular rupture risk. 1

Device-Related Complications

Device Malposition/Migration:

• If valve is unstable, rapid placement of a second overlapping valve may salvage the procedure. 1
• Ventricular embolization requires urgent surgery. 1
• Self-expanding valves (CoreValve Evolut R) can be recaptured and repositioned prior to full deployment. 1

Annular Rupture:

• Rare but devastating complication with high mortality. 1
• Predisposing factors include bulky calcification, small sinotubular junction, smaller annular size, and aggressive balloon predilation. 1
• Management options range from comfort care to emergent surgical conversion. 1

Coronary Occlusion:

• Occurs in approximately 0.5% of cases. 4
• Requires immediate recognition and intervention. 4

Atrial Fibrillation

• New-onset atrial fibrillation occurs significantly more frequently with surgical AVR than TAVR. 4
• Manage with rate control or rhythm control via pharmacological or electrical cardioversion. 1

Post-Discharge Management and Long-Term Complications

Antithrombotic Therapy

• Aspirin 75-100 mg daily lifelong for all patients. 1, 5, 3
• Clopidogrel 75 mg daily for 3-6 months. 1, 5, 3
• Consider warfarin (INR 2.0-2.5) if patient has atrial fibrillation or venous thromboembolism risk. 1, 5, 3
• Avoid triple therapy (anticoagulation plus dual antiplatelet therapy) except in extraordinary circumstances due to prohibitive bleeding risk. 3
• If on warfarin, continue low-dose aspirin but avoid adding clopidogrel. 1, 3

Structured Follow-Up Schedule

• TAVR team evaluation at 30 days post-procedure. 1, 5, 3
• Primary cardiologist at 6 months, then annually. 1, 5, 3
• Primary care physician or geriatrician at 3 months, then as needed. 1, 5, 3
• More frequent follow-up required for significant paravalvular leak or changes in clinical status. 1

Diagnostic Surveillance

• Obtain pre-discharge echocardiogram to establish baseline valve function, including transvalvular velocity, mean gradient, valve area, and paravalvular regurgitation. 1, 5, 3
• Repeat echocardiography at 30 days, then annually as needed. 1, 5, 3
• Assess LV size and function, regional wall motion, mitral valve function, pulmonary pressures, and right ventricular function. 3
• Obtain ECG at 30 days and annually. 1, 5, 3
• Pacemaker needs can emerge beyond the initial 30-day period—do not neglect late conduction abnormalities. 3

Management of Concurrent Cardiovascular Conditions

• Optimize treatment of coronary artery disease. 1, 5, 3
• Control hypertension. 1, 5, 3
• Implement guideline-directed medical therapy for heart failure/LV dysfunction. 1, 5, 3
• Manage arrhythmias, especially atrial fibrillation. 1, 5
• Monitor laboratory results for blood counts, metabolic panel, and renal function. 1, 5

Endocarditis Prevention

• Encourage optimal dental care and hygiene. 1, 5, 3
• Provide antibiotic prophylaxis per AHA/ACC guidelines for all prosthetic valves. 1, 5, 3

Rehabilitation and Lifestyle

• Mobilize patients as soon as access site allows to prevent deconditioning. 1, 5
• Initiate physical and occupational therapy assessment. 1, 5
• Promote cardiac risk factor reduction and healthy lifestyle. 1, 3
• Consider formal cardiac rehabilitation programs, especially for deconditioned patients. 3

Critical Pitfalls to Avoid

• Do not assume valve durability is indefinite—annual surveillance for structural valve deterioration is essential as long-term durability data remain limited. 3
• Readmission rates exceed 40% in the first year after TAVR, most often due to non-cardiac causes. 3
• 21.4% of TAVR patients experience at least one major complication within 30 days, significantly impacting 1-year survival and health status. 2
• Avoid early dismissal without adequate surveillance for delayed heart block. 1
• Do not overlook access site complications in transfemoral patients requiring supine positioning until hemostasis achieved. 1