What is the post-operative care regimen for a patient with a positive Aortic Valve Replacement (AVR)?

Post-Operative Care After Aortic Valve Replacement

For patients after AVR, initiate aspirin 75-100 mg daily lifelong, add clopidogrel 75 mg daily for 3-6 months (TAVR) or consider warfarin (INR 2.0-3.0) for 3 months (bioprosthetic surgical AVR), with mandatory anticoagulation per AF guidelines if atrial fibrillation is present. 1

Antithrombotic Therapy

For TAVR Patients

• Start aspirin 75-100 mg orally daily and continue lifelong 1, 2
• Add clopidogrel 75 mg orally daily for 3-6 months post-procedure (3 months for self-expanding valves, 6 months for balloon-expandable valves) 1, 2
• For patients with chronic atrial fibrillation or other anticoagulation indications, use vitamin K antagonist therapy per AF guidelines for prosthetic valves (target INR 2.0-3.0) 1, 3
• When anticoagulation is used, continuation of aspirin is reasonable, but avoid triple therapy (anticoagulation + dual antiplatelet) due to prohibitive bleeding risk 1, 2
• Vitamin K antagonist therapy may be considered in the first 3 months after TAVR in patients at risk of AF or valve thrombosis, depending on individual risk-benefit assessment 1

For Bioprosthetic Surgical AVR

• Warfarin with target INR 2.5 (range 2.0-3.0) may be reasonable for at least 3 months, and perhaps up to 6 months after bioprosthetic AVR 1, 3
• The FDA label supports warfarin therapy with target INR 2.5 (range 2.0-3.0) for bioprosthetic valves in the aortic position for the first 3 months after valve insertion 3
• A large observational registry demonstrated stroke rate reduction from 7.00 to 2.69 per 100 person-years with warfarin therapy, with benefits persisting at 6 months 1

Critical Anticoagulation Warnings

• Never use direct oral anticoagulants (dabigatran, apixaban, rivaroxaban) in patients with mechanical valve prostheses due to excessive thrombotic complications 1
• For mechanical valves, warfarin is mandatory with target INR based on valve type and position (INR 2.5 for bileaflet aortic valves, INR 3.0 for mitral position or tilting disk valves) 3

Follow-Up Schedule and Care Coordination

Immediate Post-Procedure (First 30 Days)

• The Heart Valve Team maintains primary responsibility for care during the first 30 days when procedural complications are most likely 1, 2
• Perform continuous telemetry and vital sign monitoring during recovery from sedation/anesthesia 1, 4
• Obtain pre-discharge echocardiogram to establish baseline valve function, including transvalvular velocity, mean gradient, valve area, and paravalvular regurgitation assessment 1, 2, 4
• Obtain baseline ECG to document conduction status 1, 4
• Monitor access site meticulously for bleeding, hematoma, or pseudoaneurysm formation 1, 4
• Mobilize patients as soon as access site allows to prevent deconditioning 1, 4

Structured Long-Term Follow-Up

• TAVR team evaluation at 30 days post-procedure 1, 2, 4
• Primary cardiologist appointment at 6 months, then annually (more frequently if complications or concurrent conditions develop) 1, 2, 4
• Primary care provider or geriatrician appointment within 3 months, then as needed for comorbidity management 1, 2, 4
• Formal transfer of care from Heart Valve Team to primary cardiologist occurs after 30 days in stable patients 1

Diagnostic Monitoring

Echocardiographic Surveillance

• Repeat echocardiography at 30 days, then at least annually to monitor valve function and detect complications 1, 2
• Key parameters to assess include: LV size and ejection fraction, regional wall motion, mitral valve function, pulmonary pressures, right ventricular function, and paravalvular regurgitation 1, 2
• Additional echocardiography is indicated for new symptoms suggestive of prosthetic dysfunction or worsening LV function 1

Electrocardiographic Monitoring

• Perform ECG at 30 days and annually 1, 2, 4
• Periodic ECG monitoring is recommended for detection of asymptomatic atrial fibrillation 1
• Consider 24-hour ECG monitoring if bradycardia is present, as heart block or conduction defects can occur late after TAVR 1, 2

Management of Cardiac Comorbidities

Concurrent Conditions Requiring Attention

• Implement guideline-directed medical therapy for heart failure and LV systolic dysfunction 1, 2
• Manage hypertension, coronary artery disease, and mitral valve disease per standard guidelines 1, 2
• Monitor for and treat atrial fibrillation (present in ~25% pre-TAVR, with 1-8.6% new-onset post-TAVR) 1
• Address pulmonary hypertension and LV diastolic dysfunction as indicated 1

Non-Cardiac Comorbidity Management

• Primary care provider or geriatrician should manage pulmonary disease, renal disease, arthritis, frailty, and cognitive impairment 1, 4
• Cardiologist provides consultation for changes in cardiac signs or symptoms 1
• Referral back to Heart Valve Team is appropriate when prosthetic valve dysfunction is suspected or if additional interventional procedures are needed 1

Endocarditis Prevention

• Encourage optimal dental care and regular dental visits for routine cleaning 1, 2, 4
• Provide antibiotic prophylaxis per AHA/ACC guidelines for all prosthetic valves 1, 2, 4
• Standard endocarditis prophylaxis applies to all patients with prosthetic heart valves 2

Critical Pitfalls to Avoid

Valve Thrombosis Recognition

• Maintain high suspicion for valve thrombosis in any patient with prosthetic valve presenting with recent increase in dyspnea or fatigue 1
• Valve thrombosis can develop slowly over days to weeks, particularly after interrupted or subtherapeutic anticoagulation 1
• Risk is highest in unanticoagulated patients with bioprostheses in setting of low cardiac output 1
• If valve thrombosis is suspected, immediately transfer to cardiac center after giving 5000 units heparin IV 1

Anticoagulation Management Errors

• Do not use triple therapy (warfarin + aspirin + clopidogrel) except in extraordinary circumstances due to excessive bleeding risk 1, 2
• When vitamin K antagonist is used with aspirin, avoid adding other antiplatelet agents 1
• Never use direct oral anticoagulants in mechanical valve patients 1

Late Complications

• Do not neglect late conduction abnormalities—pacemaker needs can emerge beyond 30 days 2
• Do not assume indefinite valve durability—annual surveillance for structural valve deterioration is essential as long-term data remain limited 2
• Readmission rates exceed 40% in the first year after TAVR, most often due to non-cardiac causes 2

Fluid and Hemodynamic Management

• Maintain adequate hydration and avoid early aggressive diuretic administration to minimize acute kidney injury risk 4, 5
• Provide adequate fluid resuscitation while closely monitoring volume status to prevent both hypovolemia and fluid overload 5
• Monitor intake and output strictly to guide fluid management 1, 4, 5