Post TAVR management
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Aortic Stenosis Microchapters |
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Diagnosis |
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Treatment |
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Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty |
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Transcatheter Aortic Valve Replacement (TAVR) |
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Case Studies |
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Post TAVR management On the Web |
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American Roentgen Ray Society Images of Post TAVR management |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]
Overview
Long-term management of patients after TAVR is similar to that of patients after SAVR. Periodic patient monitoring for valve function, cardiac conduction defects, arrhythmia, comorbidties, antithrombotic therapy, patient education, dental hygiene and endocarditis prophylaxis and cardiac rehabilitation and physical therapy are the basic components of post procedure care.
Post TAVR clinical management
The long-term management of patients after TAVR is similar to that of patients after SAVR. The major differences are that patients undergoing TAVR tend to be older and have more comorbid
conditions; an access site replaces the surgical incision; and the long-term durability of transcatheter valves is not yet known.
Basic principles for management of patients after valve replacement include:
- Periodic monitoring of prosthetic valve function
- Management of comorbid conditions
- Monitoring for cardiac conduction defects and heart block
- Promotion of a healthy lifestyle with cardiac risk factor reduction
- Antithrombotic therapy as appropriate
- Optimal dental hygiene and endocarditis prophylaxis
- Patient education and coordination of care
- Cardiac rehabilitation and promotion of physical activity as appropriate.
The following table describes Checklist for Post-TAVR Clinical Management.
Abbreviations:
ACC:American College of Cardiology; ADLs: activities of daily living; AF: atrial fibrillation; AHA:
American Heart Association; AR: aortic regurgitation; ASA: aspirin; ECG: electrocardiogram; GI: gastrointestinal; LV: left ventricular; MD: medical doctor; NOAC: new oral anticoagulant; OT: occupational therapy; PA: pulmonary artery; PT: physical therapy; TAVR: transcatheter aortic valve replacement; VTE: venous thromboembolism.
| Checklist for Post-TAVR Clinical Management | ||
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| Key Steps | Essential Elements | Additional Details |
| Immediate Postprocedure Management | ||
| Waking from sedation |
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| Post-procedure monitoring |
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| Pain management |
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| Early mobilization |
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Encourage physical activity |
| Discharge planning |
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| Long-Term Follow-up | ||
| Timing |
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| Antithrombotic therapy |
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| Concurrent cardiac disease |
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| Monitor for post-TAVR
complications |
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| Dental hygiene and
antibiotic prophylaxis |
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Immediate Postprocedure Management
After TAVR procedure, patients should be monitored for recovery from sedation and anesthesia.
Waking from sedation
When general anesthesia is used, early extubation is encouraged, as for any general anesthesia procedure.
Postprocedure Monitoring
Monitoring for mental status, telemetry, vital signs, volume status, postprocedure blood testing and access site for adequate hemostasis is required for either conscious sedation or general anesthesia.
Pain Management
Appropriate pain management, continued mental status monitoring, and early mobilization are especially important post-TAVR as patients often are elderly with a high burden of comorbidities.
Early Mobilization
Discharge plan should be prepared before the procedure and should include physical and occupational therapy.
Discharge Planning
Early discharge (within 72 hours) does not increase the risk of 30-day mortality, bleeding, pacer implantation or re-hospitalization in selected patients undergoing transfemoral TAVR.[1]
Long Term Follow up
Timing
Integration and coordination of medical care is essential post-TAVR to ensure optimal patient outcomes. Outcomes after TAVR depend strongly on overall patient health and clinical conditions other than the aortic valve disease.[2]
Readmission rates are over 40% in the first year after the procedure, most often due to non-cardiac causes (60% of re-admissions); common readmission diagnoses include respiratory problems, infections and bleeding events. Cardiac re-admissions are most often for arrhythmias or heart failure.[3][4]
Mortality rates after TAVR remain very high, with about 30% of patients dying within 3 years of the procedure[5][6]. Non-cardiac causes of death predominate after the first 6 months. These data emphasize the need for integrated non-cardiac and cardiac care in these patients, including end-of-life planning.
The Heart Valve Team is responsible for care for the first 30 days because procedural complications are most likely in this time interval. After 30 days, there should be a formal transfer of care from the Heart Valve Team back to the referring primary cardiologist. In stable patients with no complications and few co-morbidities, the primary cardiologist should see the patient at 6 months and then annually, and more frequently as needed for complications or concurrent medical conditions. The primary care provider and cardiologist should communicate frequently to ensure coordination of care, with clear patient instructions on when and how to contact the care team.
Antithrombotic Therapy
The current standard antithrombotic therapy after TAVR is clopidogrel 75 mg orally daily for 3–6 months with oral aspirin 75–100 mg daily lifelong. Patients with chronic AF or other indications for long-term anticoagulation should receive anticoagulation as per guidelines for AF in patients with prosthetic heart valves. Vitamin-K antagonist therapy may be considered in the first 3 months after TAVR in patients at risk of AF or valve thrombosis, depending on the specific risk-benefit ratio in that patient. When vitamin-K antagonist therapy is used, continuation of aspirin is reasonable, but it may be prudent to avoid other antiplatelet therapy in some patients given the increased risk of bleeding with multiple simultaneous antithrombotic agents.
Concurrent Cardiac Disease
Long-term management focuses on treatment of comorbid cardiac and non-cardiac conditions.
| Cardiac comorbidities | Noncardiac
comorbidities |
|---|---|
| Hypertension | Pulmonary disease |
| Coronary artery disease | Renal disease |
| AF | |
| LV systolic | Frailty |
| LV diastolic | Arthritis |
| MV disease | Cognitive impairment |
| Pulmonary hypertension |
non-cardiac conditions are best managed by the primary care provider or geriatrician, with the cardiologist providing consultation regarding any changes in cardiac signs or symptoms. Referral back to the Heart Valve Team is appropriate when prosthetic valve dysfunction is a concern or if a second interventional procedure might be needed for another valve or for coronary artery disease. In addition to echocardiography, periodic ECG monitoring is recommended for detection of asymptomatic AF and because heart block or other conduction defects can occur late after TAVR.
Monitor for Post-TAVR Complications
Echocardiography before discharge provides a new baseline study of transcatheter valve function and should include:
the antegrade TAVR velocity, mean transaortic gradient, valve area, assessment of paravalvular AR, LV size, regional wall motion and ejection fraction, evaluation of MV anatomy and function, estimation of pulmonary pressures and evaluation of the right ventricle.
Repeat echocardiography is recommended at 30 days and then at least annually.
Routine ECG assessment is also recommended owing to a potential need for pacemaker implantation beyond the initial 30-day period, particularly following implantation of the self expanding
TAVR.
The TAVR procedure is associated with a high risk of dislodgement of microdebris from arch atheroma or from the valve itself with subsequent embolic stroke. Clinical cerebrovascular
event rates are around 3%–5% at 30 days.[7][8]
Dental Hygiene and Antibiotic Prophylaxis
A TAVR is a risk factor for endocarditis, with reported rates of early prosthetic valve endocarditis ranging from 0.3% to 3.4 % per patient-year.[9][10]
Standard antibiotic
prophylaxis after TAVR is the same as for all prosthetic valves per ACC Guidelines.[11] In addition, patients should be encouraged to use optimal dental hygiene and see a dentist regularly for routine cleaning and dental care, with antibiotic prophylaxis at each visit.
References
- ↑ Barbanti M, Capranzano P, Ohno Y, Attizzani GF, Gulino S, Immè S, Cannata S, Aruta P, Bottari V, Patanè M, Tamburino C, Di Stefano D, Deste W, Giannazzo D, Gargiulo G, Caruso G, Sgroi C, Todaro D, di Simone E, Capodanno D, Tamburino C (2015). "Early discharge after transfemoral transcatheter aortic valve implantation". Heart. 101 (18): 1485–90. doi:10.1136/heartjnl-2014-307351. PMID 26076940.
- ↑ Beohar N, Zajarias A, Thourani VH, Herrmann HC, Mack M, Kapadia S, Green P, Arnold SV, Cohen DJ, Généreux P, Xu K, Leon MB, Kirtane AJ (2014). "Analysis of early out-of hospital mortality after transcatheter aortic valve implantation among patients with aortic stenosis successfully discharged from the hospital and alive at 30 days (from the placement of aortic transcatheter valves trial)". Am. J. Cardiol. 114 (10): 1550–5. doi:10.1016/j.amjcard.2014.08.021. PMC 4482466. PMID 25277334.
- ↑ Durand E, Eltchaninoff H, Canville A, Bouhzam N, Godin M, Tron C, Rodriguez C, Litzler PY, Bauer F, Cribier A (2015). "Feasibility and safety of early discharge after transfemoral transcatheter aortic valve implantation with the Edwards SAPIEN-XT prosthesis". Am. J. Cardiol. 115 (8): 1116–22. doi:10.1016/j.amjcard.2015.01.546. PMID 25726383.
- ↑ Nombela-Franco L, del Trigo M, Morrison-Polo G, Veiga G, Jimenez-Quevedo P, Abdul-Jawad Altisent O, Campelo-Parada F, Biagioni C, Puri R, DeLarochellière R, Dumont E, Doyle D, Paradis JM, Quirós A, Almeria C, Gonzalo N, Nuñez-Gil I, Salinas P, Mohammadi S, Escaned J, Fernández-Ortiz A, Macaya C, Rodés-Cabau J (2015). "Incidence, Causes, and Predictors of Early (≤30 Days) and Late Unplanned Hospital Readmissions After Transcatheter Aortic Valve Replacement". JACC Cardiovasc Interv. 8 (13): 1748–57. doi:10.1016/j.jcin.2015.07.022. PMID 26476610.
- ↑ Mack MJ, Leon MB, Smith CR, Miller DC, Moses JW, Tuzcu EM, Webb JG, Douglas PS, Anderson WN, Blackstone EH, Kodali SK, Makkar RR, Fontana GP, Kapadia S, Bavaria J, Hahn RT, Thourani VH, Babaliaros V, Pichard A, Herrmann HC, Brown DL, Williams M, Akin J, Davidson MJ, Svensson LG (2015). "5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial". Lancet. 385 (9986): 2477–84. doi:10.1016/S0140-6736(15)60308-7. PMID 25788234.
- ↑ Saia F, Latib A, Ciuca C, Gasparetto V, Napodano M, Sticchi A, Anderlucci L, Marrozzini C, Naganuma T, Alfieri O, Facchin M, Hoxha B, Moretti C, Marzocchi A, Colombo A, Tarantini G (2014). "Causes and timing of death during long-term follow-up after transcatheter aortic valve replacement". Am. Heart J. 168 (5): 798–806. doi:10.1016/j.ahj.2014.07.023. PMID 25440810.
- ↑ Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Brown DL, Block PC, Guyton RA, Pichard AD, Bavaria JE, Herrmann HC, Douglas PS, Petersen JL, Akin JJ, Anderson WN, Wang D, Pocock S (2010). "Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery". N. Engl. J. Med. 363 (17): 1597–607. doi:10.1056/NEJMoa1008232. PMID 20961243.
- ↑ Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ (2011). "Transcatheter versus surgical aortic-valve replacement in high-risk patients". N. Engl. J. Med. 364 (23): 2187–98. doi:10.1056/NEJMoa1103510. PMID 21639811.
- ↑ Amat-Santos IJ, Messika-Zeitoun D, Eltchaninoff H, Kapadia S, Lerakis S, Cheema AN, Gutiérrez-Ibanes E, Munoz-Garcia AJ, Pan M, Webb JG, Herrmann HC, Kodali S, Nombela-Franco L, Tamburino C, Jilaihawi H, Masson JB, de Brito FS, Ferreira MC, Lima VC, Mangione JA, Iung B, Vahanian A, Durand E, Tuzcu EM, Hayek SS, Angulo-Llanos R, Gómez-Doblas JJ, Castillo JC, Dvir D, Leon MB, Garcia E, Cobiella J, Vilacosta I, Barbanti M, R Makkar R, Ribeiro HB, Urena M, Dumont E, Pibarot P, Lopez J, San Roman A, Rodés-Cabau J (2015). "Infective endocarditis after transcatheter aortic valve implantation: results from a large multicenter registry". Circulation. 131 (18): 1566–74. doi:10.1161/CIRCULATIONAHA.114.014089. PMID 25753535.
- ↑ Latib A, Naim C, De Bonis M, Sinning JM, Maisano F, Barbanti M, Parolari A, Lorusso R, Testa L, Actis Dato GM, Miceli A, Sponga S, Rosato F, De Vincentiis C, Werner N, Fiorina C, Bartorelli A, Di Gregorio O, Casilli F, Muratori M, Alamanni F, Glauber M, Livi U, Nickenig G, Tamburino C, Alfieri O, Colombo A (2014). "TAVR-associated prosthetic valve infective endocarditis: results of a large, multicenter registry". J. Am. Coll. Cardiol. 64 (20): 2176–8. doi:10.1016/j.jacc.2014.09.021. PMID 25457406.
- ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD (2014). "2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". J. Am. Coll. Cardiol. 63 (22): e57–185. doi:10.1016/j.jacc.2014.02.536. PMID 24603191.