What is the management approach for an older patient with a history of valvular heart disease who develops hemolytic anemia after Transcatheter Aortic Valve Replacement (TAVR)?

Management of Hemolytic Anemia Post-TAVR

Hemolytic anemia after TAVR is almost always caused by paravalvular leak (PVL), and the primary management decision is whether to pursue percutaneous PVL closure versus medical management with oral iron supplementation, based on the severity of hemolysis and PVL. 1

Initial Diagnostic Workup

Obtain urgent echocardiography to identify and quantify paravalvular regurgitation, as this is the most common mechanism causing hemolysis after TAVR through mechanical trauma to red blood cells from regurgitant jets. 1, 2 The ACC guidelines recommend echocardiography at 30 days post-TAVR and annually thereafter, but symptomatic anemia warrants immediate imaging. 3

Confirm hemolytic anemia with laboratory studies including:

• Complete blood count showing anemia 3
• Elevated lactate dehydrogenase (LDH) 2
• Decreased haptoglobin 2
• Elevated indirect bilirubin 2
• Peripheral smear showing schistocytes 2
• Elevated reticulocyte count 2

Transesophageal echocardiography (TEE) with color Doppler is superior to transthoracic imaging for detecting and characterizing PVL, particularly for planning percutaneous intervention. 4, 2

Management Algorithm

Mild Hemolysis with Minimal PVL

Start oral iron supplementation as first-line therapy for patients with mild anemia and laboratory evidence of hemolysis but without severe symptoms. 2 This approach is appropriate when:

• Hemoglobin remains >10 g/dL
• No heart failure symptoms
• Minimal PVL on echocardiography

Monitor hemoglobin levels every 4-6 weeks during follow-up visits with the TAVR team at 30 days and primary cardiologist at 6 months. 3

Moderate to Severe Hemolysis with Significant PVL

Pursue percutaneous PVL closure with occluder devices when hemolysis is clinically significant, as recent case series demonstrate successful resolution of hemolytic anemia with this approach. 1 Indications include:

• Transfusion-dependent anemia
• Hemoglobin <10 g/dL despite iron supplementation
• Heart failure symptoms attributable to PVL
• Moderate or greater paravalvular regurgitation on echocardiography 3

The 2025 case series showed complete resolution of hemolytic anemia after percutaneous PVL plugging with Amplatzer devices under TEE guidance. 1 This represents a significant advance over the older recommendation for surgical valve replacement. 2

Surgical Intervention

Reserve redo valve surgery for patients with:

• Failed percutaneous closure attempts
• Anatomically unsuitable PVL for percutaneous approach
• Concurrent structural problems requiring surgical correction (e.g., pannus formation, subvalvular stenosis) 5

Common Pitfalls and Caveats

Do not attribute post-TAVR anemia solely to chronic disease or renal dysfunction without excluding PVL-related hemolysis. While anemia is common in elderly TAVR patients (67.5% pre-procedure), hemoglobin typically improves 5-12 months post-TAVR as gastrointestinal blood loss from AS syndrome resolves. 6 New or worsening anemia warrants investigation for hemolysis.

The severity of PVL on echocardiography does not always correlate with the degree of hemolysis. Even mild paravalvular regurgitation can cause significant hemolytic anemia through turbulent flow. 5, 1 Therefore, clinical and laboratory evidence of hemolysis should drive management decisions, not echocardiographic grading alone.

The 2012 ACC consensus document noted no reported cases of hemolysis with TAVR despite paravalvular regurgitation 3, but more recent evidence clearly demonstrates this complication occurs and requires recognition. 1 This highlights the evolving understanding of TAVR complications with longer follow-up.

Monitoring During Treatment

Continue routine post-TAVR surveillance per ACC guidelines:

• Monitor blood counts at follow-up visits 3
• Repeat echocardiography if clinical status changes 3
• Maintain aspirin 75-100 mg daily lifelong 3
• Continue clopidogrel 75 mg daily for 3-6 months post-procedure 3

Coordinate care between the TAVR team, primary cardiologist, and primary care physician to ensure appropriate monitoring and timely intervention if hemolysis persists or worsens. 3