From the Guidelines
For TAVER follow-up, I recommend a comprehensive approach including close monitoring by the implanting physician team for the first 30 days, followed by scheduled visits with the primary cardiologist at 6 months, 1 year, and annually thereafter, with increased frequency if significant post-TAVR paravalvular leak or changes in clinical status occur. This approach is based on the most recent guidelines, including the 2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement 1.
Key Components of Follow-Up
- Echocardiogram at 30 days, 6 months, and annually to monitor valve function, with attention to any paravalvular leak, valve degeneration, or changes in gradients
- Regular clinical assessments at 1 month, 6 months, and annually to evaluate for symptoms of heart failure, arrhythmias (particularly atrial fibrillation), and stroke
- Antithrombotic therapy, including aspirin 75-100 mg daily lifelong and clopidogrel 75 mg daily for 3-6 months, as recommended by the 2017 ACC guidelines 1
- Consideration of warfarin (INR 2.0-2.5) if at risk of atrial fibrillation or venous thromboembolism
- Monitoring for post-TAVR complications, including paravalvular leak, valve thrombosis, and conduction abnormalities
Coordination of Care
- Coordination of care among the TAVR team, primary cardiologist, and primary care physician to ensure comprehensive management of the patient's condition
- Regular communication with the patient to report any symptoms, such as shortness of breath, chest pain, dizziness, or palpitations, immediately
- Encouragement of optimal dental care and antibiotic prophylaxis per AHA/ACC guidelines, as recommended by the 2017 ACC expert consensus decision pathway 1
Rationale
The recommended follow-up approach is based on the most recent guidelines and expert consensus, which emphasize the importance of close monitoring and comprehensive management of patients after TAVR. This approach is crucial for early detection of complications, such as paravalvular leak or valve thrombosis, and for optimizing the patient's quality of life and reducing morbidity and mortality, as highlighted in the 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement 1.
From the Research
TAVR Follow-Up
- The decision to choose between transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) in intermediate-surgical-risk patients with severe, symptomatic aortic stenosis is influenced by several factors, including advances in transcatheter valve technology and techniques, as well as trials demonstrating non-inferiority compared to SAVR 2.
- Results from the PARTNER II intermediate risk trials and SURTAVI trials have provided insight into the benefits and potential risks of both treatment modalities 2.
- TAVR is a less invasive alternative to traditional SAVR, with equivalent or superior outcomes, and its use has increased rapidly due to advances in technology, greater operator experience, and improved outcomes 3.
- However, remaining challenges include the management of coexistent coronary artery disease, prevention of periprocedural stroke, and issues of durability, which are particularly relevant for low-risk, younger patients 3.
- The choice of therapy should be based on a transparent process that considers medical evidence and patients' values and preferences, and physicians should be aware of their own biases and how they may influence their recommendations 4.
Considerations for TAVR
- TAVR has expanded eligibility to both intermediate-risk patients in clinical practice and low-risk patients in pivotal trials 2, 3.
- The procedure-related morbidity and patient survivability require careful consideration, particularly in younger patients with longer life expectancy 2, 3.
- Valve durability is also a concern, and further research is needed to fully understand the long-term outcomes of TAVR 3.
Related Conditions
- Hypertension and type 2 diabetes are common comorbidities, and their relationship is closely interlinked due to similar risk factors, such as endothelial dysfunction and vascular inflammation 5.
- Intensive blood pressure control and management of diabetes are crucial to reduce cardiovascular morbidity and mortality in patients with these conditions 6, 5.