What is the recommended follow‑up schedule and management after transcatheter aortic valve replacement (TAVR)?

Post-TAVR Follow-Up Management

After TAVR, patients require structured follow-up with the TAVR team at 30 days, primary cardiologist at 6 months then annually, and primary care physician at 3 months and as needed, with baseline echocardiography and ECG at 30 days followed by annual surveillance. 1, 2

Follow-Up Schedule and Care Coordination

First 30 Days: TAVR Team Responsibility

• The TAVR team maintains primary responsibility during the first 30 days to identify and manage procedural complications. 1, 2
• Obtain baseline echocardiogram and ECG during this period to document valve function and detect conduction abnormalities. 1, 2, 3
• Monitor continuously with telemetry for at least 48-72 hours post-procedure, as complete heart block can occur up to 30 days after TAVR, particularly with self-expanding valves. 3
• Consider 24-hour Holter monitoring if bradycardia develops. 1, 2, 3

Subsequent Follow-Up Timeline

• Primary cardiologist assumes care after 30 days, seeing patients at 6 months, then annually. 1, 2
• Primary care physician or geriatrician should evaluate at 3 months and as needed thereafter. 2, 3
• Increase frequency of visits if significant paravalvular leak or clinical status changes occur. 1, 2

Antithrombotic Management

All patients should receive aspirin 75-100 mg daily lifelong plus clopidogrel 75 mg daily for 3-6 months. 1, 2, 3

Special Considerations

• Consider warfarin (INR 2.0-2.5) if atrial fibrillation or venous thromboembolism risk exists. 1, 2, 3
• In patients already on oral anticoagulation for atrial fibrillation, continue low-dose aspirin but avoid additional antiplatelet therapy to minimize bleeding risk. 1, 2
• Avoid triple antithrombotic therapy due to prohibitive bleeding risk in this elderly population. 1

Diagnostic Surveillance

Echocardiography Protocol

• Perform echocardiography at 30 days to establish baseline valve function, then annually. 1, 2, 3
• Increase frequency if moderate or severe paravalvular regurgitation is detected or clinical status changes. 1, 2
• Monitor specifically for paravalvular aortic regurgitation, which occurs in approximately 7% of patients at moderate or severe levels by 1 year. 4
• Assess left ventricular function, prosthetic valve hemodynamics, and signs of endocarditis. 5, 6

Electrocardiographic Monitoring

• Obtain ECG at 30 days and annually to detect conduction disturbances. 1, 2, 5
• Pre-existing conduction delays significantly increase pacemaker risk, requiring enhanced surveillance. 3

Management of Concurrent Conditions

Cardiovascular Disease Management

• Actively manage coronary artery disease, hypertension, heart failure, and arrhythmias (especially atrial fibrillation). 1, 2
• For hypertension with wide pulse pressure, use ACE inhibitors or ARBs rather than beta blockers, as beta blockers paradoxically worsen pulse pressure by reducing heart rate and increasing stroke volume. 4
• Monitor laboratory results including blood counts, metabolic panel, and renal function. 1

Non-Cardiac Comorbidities

• Readmission rates exceed 40% in the first year, with 60% due to non-cardiac causes including respiratory problems, infections, and bleeding events. 1
• Assess pulmonary, renal, gastrointestinal, and neurological function annually or as needed. 1
• Manage diabetes and dyslipidemia according to standard guidelines. 2

Endocarditis Prophylaxis and Dental Care

• Provide antibiotic prophylaxis per AHA/ACC guidelines for all prosthetic valves before specific dental procedures. 1, 2, 3
• Encourage optimal dental hygiene to prevent endocarditis. 1, 2

Rehabilitation and Lifestyle Modification

• Promote cardiac rehabilitation and physical activity as appropriate. 1, 2
• Initiate physical and occupational therapy assessment early to prevent deconditioning. 1, 3
• Implement cardiac risk factor reduction and healthy lifestyle promotion. 1, 2

Critical Complications to Monitor

Early Complications (0-30 Days)

• Complete heart block requiring permanent pacemaker is the most common cardiac complication, occurring more frequently with self-expanding valves. 3
• Monitor access site carefully for bleeding, hematoma, or pseudoaneurysm formation. 1
• Assess for moderate to severe paravalvular regurgitation, which is associated with increased mortality and reduced quality of life. 3

Long-Term Outcomes

• Mortality rates remain high, with approximately 30% of patients dying within 3 years, predominantly from non-cardiac causes after the first 6 months. 1, 7
• Structural valve deterioration occurs in approximately 3.3% of patients, with bioprosthetic valve failure in 2.4% during long-term follow-up. 8

Patient Education

• Provide comprehensive discharge instructions regarding warning signs requiring urgent evaluation. 2
• Ensure patients understand the importance of medication adherence, particularly antithrombotic therapy. 2
• Coordinate care among TAVR team, primary cardiologist, and primary care physician to optimize outcomes. 1, 2