Is a patient with a history of Hypertension (HTN), Hyperlipidemia (HLD), Diabetes Mellitus type 2 (DM 2), Benign Prostatic Hyperplasia (BPH), and Aortic Stenosis (AS) status post Transcatheter Aortic Valve Replacement (TAVR) cleared for Transurethral Resection of the Prostate (TURP) and total left knee replacement surgeries from a cardiovascular standpoint?

Cardiovascular Clearance for TURP and Total Knee Replacement Post-TAVR

This patient is cleared for both TURP and total left knee replacement from a cardiovascular standpoint, as he is well beyond the critical 30-day post-TAVR period, has a normally functioning prosthetic valve, preserved LV function, and is clinically stable with good functional capacity.

Timing Considerations Post-TAVR

The most critical factor for surgical clearance after TAVR is the time interval from the procedure:

• The Heart Valve Team is responsible for care during the first 30 days post-TAVR, as procedural complications are most likely during this interval 1
• After 30 days, formal transfer of care occurs to the primary cardiologist, and patients can be considered for elective non-cardiac surgery 1
• This patient is several months post-TAVR (beyond the 3-month window mentioned in the note), placing him well outside the high-risk perioperative period 1

Prosthetic Valve Function Assessment

The patient's cardiovascular status supports surgical clearance:

• Recent echocardiography demonstrates normal gradients for the prosthetic aortic valve with structurally and functionally normal valve 1
• LV function remains preserved at 50-55% 1
• The patient reports symptomatic improvement (less fatigue, no dyspnea with stairs), indicating successful TAVR outcome 1

Antithrombotic Management Perioperatively

Critical consideration: The patient's antiplatelet regimen must be managed appropriately around surgery 2:

• Standard post-TAVR therapy includes clopidogrel 75 mg daily for 3-6 months plus aspirin 75-100 mg daily lifelong 1, 2
• The note indicates clopidogrel was held 7 days prior to TURP, which is appropriate practice 2
• Aspirin should generally be continued perioperatively unless bleeding risk is prohibitive 2
• After the 3-6 month dual antiplatelet period, aspirin monotherapy lifelong is the standard 1, 2

Blood Pressure Optimization

While the patient has been cleared, ongoing hypertension management is essential:

• The patient demonstrated hypertensive readings at multiple visits despite medication adjustments 1
• Home blood pressure readings appear better controlled (120s-130s systolic) 1
• Adequate blood pressure control reduces perioperative cardiovascular risk and should be optimized before elective surgery 1
• Continue current antihypertensive regimen and ensure blood pressure is monitored closely perioperatively 1

Risk Stratification Context

Understanding the post-TAVR population helps contextualize this clearance:

• TAVR patients have high readmission rates (>40% in the first year), most often due to non-cardiac causes including infections 1
• Heart failure decompensation is the most common cause of cardiac readmission post-TAVR 3
• This patient's preserved LV function, normal valve gradients, and good functional status place him at lower risk 3
• Mortality after TAVR remains approximately 30% at 3 years, predominantly from non-cardiac causes after 6 months 1

Perioperative Monitoring Recommendations

For both procedures, ensure:

• Continuation of aspirin perioperatively (clopidogrel already discontinued per protocol) 2
• Aggressive blood pressure management to avoid hypertensive episodes that could stress the prosthetic valve 1
• Adequate hydration to minimize renal complications, particularly important given the patient's diabetes and prior kidney stone 1
• Prophylactic antibiotics for endocarditis are NOT routinely recommended for TURP or orthopedic procedures in patients with prosthetic valves (based on general cardiology knowledge, though the note mentions discussion of dental prophylaxis) 1

Common Pitfalls to Avoid

• Do not delay necessary surgery indefinitely in stable post-TAVR patients beyond 30 days - the patient's quality of life (knee pain) must be balanced against cardiovascular risk 1
• Avoid perioperative hypotension which could compromise coronary perfusion in this patient with multiple cardiac risk factors 1
• Do not restart clopidogrel too early postoperatively if significant bleeding risk exists from TURP 2
• Monitor for atrial fibrillation perioperatively, as new-onset AF occurs in up to 8.6% post-TAVR and can occur late 1, 2