Zubair Ahmed MD FSCAI Interventional Cardiologist

Washington Regional Medical Center / Walker Heart Institute

TAVR : Caring for your patients before and after TAVR

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

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

Symptoms

• Chest pain

• Fatigue

• Shortness of breath

• Lightheadedness or dizziness with exercise

• Swollen ankles or legs

• Syncope

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

Predicted survival of inoperable patients with severe AS treated with standard non-surgical

therapy is lower than common metastatic cancers

33-60% symptomatic AS pt’s are not getting treatment

Curr Probl Cardiol 2007, Eur Hrt Jou 2012

Out-Patient Visits

• Detailed History and physical

• Symptoms suggestive of Aortic Stenosis

• Other symptoms similar to Aortic Stenosis : Left Ventricular Outflow Obstruction (HOCM)

Murmur : Aortic Stenosis

• Murmur suggestive of Aortic Stenosis….Echocardiogram

• Change in nature of murmur

• Sudden change in symptoms with known Aortic Stenosis

Road to TAVR

Clinic day • Interventional Cardiologist visit

• Cardio Thoracic Surgery visit

• TAVR education

• Labs

• Tests

• Frailty testing & QOL assessment

• CTA following day

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

Complications of TAVR

• Acute : Short term in Hospital

• Long : Post Discharge

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

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

Complications of TAVR : Vascular • Reported Vascular

complications vary between 8-15%

• Predictors :

• Gender

• Calcification

• Diameter

• Sheath Size

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

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

• 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

• 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

Complications of TAVR : Sub- Acute or Long Term

Circulation. 2017;136:1049–1069. DOI: 10.1161/CIRCULATIONAHA.117.028352

• 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

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.