TAVR : Caring for your patients before and after TAVR

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1 TAVR : Caring for your patients before and after TAVR Zubair Ahmed MD FSCAI Interventional Cardiologist Washington Regional Medical Center / Walker Heart Institute

2 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

3 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

4 Symptoms Chest pain Fatigue Shortness of breath Lightheadedness or dizziness with exercise Swollen ankles or legs Syncope

5 With symptom onset >50% Severe Aortic Stenosis : With symptom onset succumb over the next 2 years >50% succumb over the next 2 years Robert O. Bonow, Circulation 2015

6 Predicted survival of inoperable patients with severe AS treated with standard non-surgical therapy is lower than common metastatic cancers

7 33-60% symptomatic AS pt s are not getting treatment Curr Probl Cardiol 2007, Eur Hrt Jou 2012

8 Out-Patient Visits Detailed History and physical Symptoms suggestive of Aortic Stenosis Other symptoms similar to Aortic Stenosis : Left Ventricular Outflow Obstruction (HOCM)

9 Murmur : Aortic Stenosis Murmur suggestive of Aortic Stenosis.Echocardiogram Change in nature of murmur Sudden change in symptoms with known Aortic Stenosis

10 Road to TAVR

11 Clinic day Interventional Cardiologist visit Cardio Thoracic Surgery visit TAVR education Labs Tests Frailty testing & QOL assessment CTA following day

12 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

13 Complications of TAVR Acute : Short term in Hospital Long : Post Discharge

14 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

15 Complications of TAVR : Vascular AORTIC : Major Aortic Dissection, Rupture,Annulus rupture, Left Ventricular complications ACCESS SITE Dissection, stenosis, perforation, rupture, fistulas, nerve injury, perforation, compartment syndrome Minor Access site or access related vascular injury Distal Embolization not requiring amputation Vascular repair

16 Complications of TAVR : Vascular Reported Vascular complications vary between 8-15% Predictors : Gender Calcification Diameter Sheath Size

17 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 Patient Teaching and discharge planning - Recheck BMP and CBC post-procedure (POCT) - CXR --Replete electrolytes and recheck as needed - Ensure pt plan for discharge - Case Management involvement if concerns for discharge needs - Full TTE - CXR - Daily BMP, CBC - Daily BMP, CBC - 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

18 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

19 Complications of TAVR : Sub- Acute or Long Term Para-Valvular Leak (PVL) Heart Blocks 7-9% If concerned, 24 Hr Heart Monitor. Any syncope, evaluate Anemia ( Bleeding with Anti-Platelet, access site)

20 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 Risks for Blocks Baseline Right Bundle Branch Block Depth of Valve Implant Valve type Over-expansion of Aortic Annulus

21 Complications of TAVR : Sub- Acute or Long Term Circulation. 2017;136: DOI: /CIRCULATIONAHA

22 Complications of TAVR : Sub- Acute Valve Malfunction ( Thrombosis, Infection ) Aortic Root Dissection or Long Term 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)

23 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.