What are the priority interventions post-transcatheter aortic valve replacement (TAVR) procedure for a patient with severe aortic stenosis and potential comorbidities?

Priority Post-TAVR Interventions

The most critical immediate post-TAVR interventions focus on access site monitoring for bleeding/hematoma/pseudoaneurysm, continuous telemetry for conduction abnormalities, frequent neurological assessments for stroke detection, and careful volume status management—all while ensuring early mobilization and appropriate pain control in this elderly, high-comorbidity population. 1

Immediate Post-Procedure Monitoring (First 24-72 Hours)

Cardiovascular Surveillance

• Continuous telemetry monitoring is mandatory to detect conduction abnormalities and arrhythmias, which are among the most common cardiac causes of readmission 1
• Monitor vital signs per institutional protocol, with particular attention to blood pressure and heart rate 1
• Assess volume status meticulously through intake/output monitoring to prevent both hypovolemia and fluid overload 1, 2

Access Site Management

• Vigilant monitoring of the access site (groin or thorax) is essential to detect bleeding, hematoma formation, or pseudoaneurysm development early 1
• Ensure adequate hemostasis with normal distal blood flow 1
• Consider ultrasound of the groin site if there is any concern for pseudoaneurysm 1

Neurological Assessment

• Frequent neurological assessments are critical, as stroke rates are elevated post-TAVR (13.8% at 2 years, with 6.7% occurring in the first 30 days) 3
• Maintain continuous mental status monitoring 1

Laboratory Monitoring

• Obtain complete blood count and metabolic panel to assess for anemia and renal function 1
• Monitor for acute kidney injury, which is a recognized post-TAVR complication 4

Early Mobilization and Rehabilitation

• Mobilize patients as soon as the access site allows, as early mobilization is especially important in elderly patients with high comorbidity burden 1
• Initiate physical and occupational therapy assessment to determine appropriate post-hospitalization disposition 1
• Encourage physical activity as appropriate for the patient's condition 1, 5

Pain Management and Medication Reconciliation

• Provide appropriate pain management tailored to elderly patients 1
• Review and restart preoperative medications promptly, ensuring all appropriate medications are resumed 1, 2

Pre-Discharge Requirements

Baseline Imaging

• Obtain predischarge echocardiogram to establish baseline valve function, including transvalvular velocity, mean gradient, valve area, and assessment of paravalvular regurgitation 1, 5
• Perform predischarge ECG 1

Antithrombotic Therapy Initiation

• Start aspirin 75-100 mg daily lifelong 1, 5
• Add clopidogrel 75 mg daily for 3-6 months in patients without an indication for anticoagulation 1, 5
• Consider warfarin (INR 2.0-2.5) if the patient is at risk for atrial fibrillation or venous thromboembolism 1, 5
• Avoid triple therapy (anticoagulation + dual antiplatelet therapy) except in extraordinary circumstances due to prohibitive bleeding risk 5

Discharge Planning

• Schedule TAVR team follow-up at 30 days 1, 5
• Arrange primary cardiologist appointment at 6 months 1, 5
• Schedule primary care provider or geriatrician visit within 3 months 1, 5
• Provide clear patient instructions on when and how to contact the care team 1

Critical Pitfalls to Avoid

• Do not delay discharge unnecessarily: Early discharge within 72 hours does not increase 30-day mortality, bleeding, pacemaker implantation, or rehospitalization rates in selected transfemoral TAVR patients 1
• Do not overlook conduction abnormalities: Pacemaker needs can emerge beyond the initial 30-day period, requiring ongoing surveillance 5
• Do not underestimate readmission risk: Over 40% of patients are readmitted within the first year, with 60% of readmissions due to non-cardiac causes (respiratory problems, infections, bleeding events) 1
• Do not neglect comorbidity management: Outcomes depend strongly on overall patient health and management of conditions beyond the aortic valve disease 1

Special Considerations for High-Risk Complications

Given that mortality rates remain high (approximately 30% at 3 years), with non-cardiac causes predominating after 6 months, integrated cardiac and non-cardiac care is essential, including consideration of end-of-life planning discussions 1