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Zubair Ahmed MD FSCAI Interventional Cardiologist
Washington Regional Medical Center / Walker Heart Institute
TAVR : Caring for your patients before and after TAVR
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What is Aortic Valve Stenosis? AVA ~4 cm2
AVA < 1 cm2 Index AVA< 0.6 cm2/m2 Mean gradient: > 40 mmHg Velocity ratio: < 0.25 Jet velocity: > 4.0 m/sec
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Severe Aortic Stenosis : Asymptomatic
• Life style modification with reduced activity
• Co-morbid conditions causing symptoms
• Shortness of breath….COPD
• Tiredness….Age
• Chest pain…Coronary artery disease
• Syncope…Dehydration
• Palpitations…Baseline arrhythmia
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Symptoms
• Chest pain
• Fatigue
• Shortness of breath
• Lightheadedness or dizziness with exercise
• Swollen ankles or legs
• Syncope
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Robert O. Bonow, Circulation 2015
With symptom onset >50% succumb over the next 2 years
Severe Aortic Stenosis : With symptom onset >50% succumb over the next 2 years
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Predicted survival of inoperable patients with severe AS treated with standard non-surgical
therapy is lower than common metastatic cancers
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33-60% symptomatic AS pt’s are not getting treatment
Curr Probl Cardiol 2007, Eur Hrt Jou 2012
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Out-Patient Visits
• Detailed History and physical
• Symptoms suggestive of Aortic Stenosis
• Other symptoms similar to Aortic Stenosis : Left Ventricular Outflow Obstruction (HOCM)
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Murmur : Aortic Stenosis
• Murmur suggestive of Aortic Stenosis….Echocardiogram
• Change in nature of murmur
• Sudden change in symptoms with known Aortic Stenosis
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Road to TAVR
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Clinic day • Interventional Cardiologist visit
• Cardio Thoracic Surgery visit
• TAVR education
• Labs
• Tests
• Frailty testing & QOL assessment
• CTA following day
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TAVR Evaluation CTA Chest/Abd/Pelvis Echocardiogram Angiogram & PCI PFTs Carotid Ultrasound CT Surgery Consults : 2 Dental clearance: Frailty assessment: 5meter walk , 6 minute walk test QOL questionnaires:KCCQ-12, Katz ADL
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Complications of TAVR
• Acute : Short term in Hospital
• Long : Post Discharge
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Complications of TAVR : Acute
• Death
• Stroke
• Heart Attack
• Injury to aorta or heart requiring emergent cardiac surgery
• Placement of second heart valve
• Pericardial tamponade
• Life threatening arrhythmias, need for pacemaker,
• Bleeding requiring blood transfusion
• Renal failure requiring life-long dependency on dialysis
• Vascular injury requiring emergency surgery or stenting
• Anesthesia related problems
• Lung injury
• Radiation injury
• Infection
• Infection in heart valve
• Limb loss
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Complications of TAVR : Vascular
Minor
• Access site or access related vascular injury
• Distal Embolization not requiring amputation
• Vascular repair
Major
• AORTIC :
• Aortic Dissection, Rupture,Annulus rupture, Left Ventricular complications
• ACCESS SITE
• Dissection, stenosis, perforation, rupture, fistulas, nerve injury, perforation, compartment syndrome
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Complications of TAVR : Vascular • Reported Vascular
complications vary between 8-15%
• Predictors :
• Gender
• Calcification
• Diameter
• Sheath Size
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0-6hrs 6-12hrs 12-24hrs 24-36hrs 36-48hrs
Activity Level - HOB flat x2hrs, then <30degree
- Out of bed to chair
- PT consult
- Ambulate in room and then hallway
- Ambulate minimum TID
- Ambulate TID - No heavy lifting x 2 weeks - Progressive activity as tolerated
Labs and imaging - Recheck BMP and CBC post-procedure (POCT) - CXR --Replete electrolytes and recheck as needed
- Full TTE - CXR - Daily BMP, CBC
- Daily BMP, CBC
Patient Teaching and discharge planning
- Ensure pt plan for discharge - Case Management involvement if concerns for discharge needs
- Transfer out of ICU on post op#day1
Medications - Aspirin 81mg and Plavix 75mg should be continued - Patients on warfarin can resume dose either same
day - Select patients may be on continuous heparin
infusion - Resume beta-blocker slowly - Most needs diuresis depending on contrast used and
renal function
- Anticipate minor platelet decrease
- Resume warfarin
- Anticipate minor platelet decrease - Continue blood thinners
Hemodynamics - Diastolic hypotension is common. DBP goal >30mmHg
- Severe diastolic hypotension (DBP<30), severe dyspnea, or poor peripheral perfusion are symptoms concerning
- Systolic hypertension may need resuming oral or IV drips
- Diastolic hypotension may persist for 1-3days post TAVR
- Systolic hypertension may present a week after TAVR and requires medication adjustments.
Code status - Full code - Defer ANY discussion about goals of care at anytime to MD
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Follow up
• Discharge from IMC to Home, Home w/ home health, nursing home, rehab
• 1 week follow up for wound check and keep them out of hospital (coordinate w/ clinic, ER)
• 30 day, 1 year follow up w/ valve clinic
• Regular follow ups with primary cardiologist
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• Para-Valvular Leak (PVL)
• Heart Blocks …7-9%
• If concerned, 24 Hr Heart Monitor.
• Any syncope , evaluate Anemia ( Bleeding with Anti-Platelet, access site)
Complications of TAVR : Sub- Acute or Long Term
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• Heart Blocks …7-9%
• 60-90% in first 24Hrs
• If concerned later, 24 Hr Heart Monitor.
• Any syncope , evaluate
Complications of TAVR : Sub- Acute or Long Term
• Risks for Blocks
• Baseline Right Bundle Branch Block
• Depth of Valve Implant
• Valve type
• Over-expansion of Aortic Annulus
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Complications of TAVR : Sub- Acute or Long Term
Circulation. 2017;136:1049–1069. DOI: 10.1161/CIRCULATIONAHA.117.028352
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• Valve Malfunction ( Thrombosis, Infection )
• Aortic Root Dissection
• Infection ( Check access site ; Neck and b/l groins)
• New neurological deficit ( CVA )
• Shortness of breath ( Pericardial Tamponade, Pneumonia)
• Peripheral Vascular Disease ( Embolization from access)
Complications of TAVR : Sub- Acute or Long Term
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Conclusion
• Important to identify patients with severe aortic stenosis
• While TAVR procedure appears simple, there are both short and long term complications associated with the procedure.