From the Guidelines
A TAVR should typically be delayed if a patient's cardiovascular status is deteriorating, as proceeding with the procedure during hemodynamic instability significantly increases procedural risk. This approach is supported by guidelines that emphasize the importance of careful patient selection and optimization before undergoing TAVR 1. The 2014 AHA/ACC guideline for the management of patients with valvular heart disease recommends TAVR in patients with a prohibitive surgical risk and a predicted post-TAVR survival >12 months, but also notes that TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS 1.
When a patient's cardiovascular status is deteriorating, it is crucial to stabilize them first with appropriate medical management, which may include:
- Inotropic support such as dobutamine (starting at 2-5 mcg/kg/min and titrating as needed)
- Vasopressors like norepinephrine (0.01-3 mcg/kg/min) if hypotensive
- Diuretics such as furosemide (20-40 mg IV) for volume overload
- Possibly balloon aortic valvuloplasty as a bridge to definitive TAVR This stabilization period allows for optimization of the patient's condition, including treatment of concurrent infections, correction of electrolyte abnormalities, and management of arrhythmias 1.
The rationale for delay is that TAVR itself places significant hemodynamic stress on an already compromised cardiovascular system, and performing the procedure during instability increases the risk of procedural complications, including hypotension, arrhythmias, coronary obstruction, and even death 1. Once the patient is stabilized with improved hemodynamics, the TAVR can be performed with a more favorable risk-benefit profile. Therefore, delaying TAVR until the patient's cardiovascular status is stabilized is a prudent approach that prioritizes morbidity, mortality, and quality of life.
From the Research
Delaying TAVR for Aortic Stenosis
- The decision to delay a Transcatheter Aortic Valve Replacement (TAVR) for a patient with deteriorating cardiovascular status due to aortic stenosis should be based on individual patient risk factors and the severity of their condition 2, 3.
- For patients with severe, symptomatic aortic stenosis, TAVR has been shown to reduce mortality and improve functional status compared to standard therapy, especially in those who are not suitable candidates for surgery 4.
- However, the presence of extensive coexisting conditions may attenuate the survival benefit of TAVR 4.
- In patients with asymptomatic aortic stenosis, watchful waiting is often recommended, with serial Doppler echocardiography and cardiology referral as needed 5.
- The management of patients undergoing TAVR requires careful consideration of periprocedural medication management, including antithrombotic therapy, to minimize adverse events such as stroke and bleeding complications 2, 6.
Considerations for Delaying TAVR
- The patient's overall health status and risk factors, including the presence of comorbid conditions, should be taken into account when deciding whether to delay TAVR 3, 6.
- The severity of the aortic stenosis and the patient's symptoms should also be considered, as well as the potential benefits and risks of delaying the procedure 4, 5.
- A multidisciplinary team approach, including cardiologists, cardiothoracic surgeons, and other healthcare professionals, can help determine the best course of treatment for each individual patient 2, 3.