TAVI Postprocedural Management

  • Piera Capranzano
  • Corrado Tamburino


Despite recent progresses in technology and operator experience and high procedural success rates, the transcatheter aortic valve implantation (TAVR) is associated with a non-negligible risk of thrombotic events, especially ischemic stroke. This risk of stroke is particularly high in the periprocedural period, but it steadily maintains during follow-up [1, 2]. Multiple factors can contribute to stroke in TAVR patients, including the following: introduction and manipulation of large valve systems in calcified arteries; exposition of tissue factor or arterial embolization of thrombogenic and inflammatory material subsequent to the important tissue injury caused by the positioning and implantation of the prosthesis valve when crushing the native valve; thrombi generated in areas of turbulent flow or blood stasis created by the new device overlying the native valve, especially in the case of small valve areas; tissue injury of the aortic wall triggering the thrombus formation; thromboembolism from bioprosthetic leaflets; peripheral vascular disease; and atrial fibrillation. This latter arrhythmia, in particular, is an important contributing factor, as it is present before the procedure in a relevant proportion (about 30%) of patients undergoing TAVR. In addition, it can develop newly after TAVR during follow-up in about 20% of patients who were on sinus rhythm at the time of the procedure [3]. Of importance, the advanced age and large burden of comorbidities typical of TAVR patients lead to a frequently high CHA2DS2-VASC score associated with a high annual risk of stroke.


  1. 1.
    Barbanti M, Gulino S, Tamburino C, et al. Antithrombotic therapy following transcatheter aortic valve implantation: what challenge do we face? Expert Rev Cardiovasc Ther. 2016;14:381–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Rodés-Cabau J, Dauerman HL, Cohen MG, et al. Antithrombotic treatment in transcatheter aortic valve implantation: insights for cerebrovascular and bleeding events. J Am Coll Cardiol. 2013;62:2349–59.CrossRefPubMedGoogle Scholar
  3. 3.
    Sannino A, Gargiulo G, Schiattarella GG, et al. A meta-analysis of the impact of pre-existing and new-onset atrial fibrillation on clinical outcomes in patients undergoing transcatheter aortic valve implantation. EuroIntervention. 2015;12(8):e1047–56. pii: 20150323-05.12CrossRefGoogle Scholar
  4. 4.
    Latib A, Naganuma T, Abdel-Wahab M, et al. Treatment and clinical outcomes of transcatheter heart valve thrombosis. Circ Cardiovasc Interv. 2015;8(4).Google Scholar
  5. 5.
    Makkar RR, Fontana G, Jilaihawi H, et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med. 2015;373:2015–24.CrossRefPubMedGoogle Scholar
  6. 6.
    Hansson NC, Grove EL, Andersen HR, et al. Transcatheter aortic heart valve thrombosis: incidence, predisposing factors, and clinical implications. J Am Coll Cardiol. 2016;68(19):2059–2069. pii: S0735-1097(16)34936-1. doi: 10.1016/j.jacc.2016.08.010.CrossRefPubMedGoogle Scholar
  7. 7.
    Gènéreux P, Cohen DJ, Mack M, et al. Incidence, predictors, and prognostic impact of late bleeding complications after transcatheter aortic valve replacement. J Am Coll Cardiol. 2014;64:2605–15.CrossRefPubMedGoogle Scholar
  8. 8.
    Dangas GD, Lefèvre T, Kupatt C, et al. Bivalirudin versus heparin anticoagulation in transcatheter aortic valve replacement: the randomized BRAVO-3 trial. J Am Coll Cardiol. 2015;66:2860–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Ussia GP, Scarabelli M, Mulè M, et al. Dual antiplatelet therapy vs aspirin alone in patients undergoing transcatheter aortic valve implantation. Am J Cardiol. 2011;108:1772–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Stabile E, Pucciarelli A, Cota L, et al. SAT-TAVI (single antiplatelet therapy for TAVI) study: a pilot randomized study comparing double to single antiplatelet therapy for transcatheter aortic valve implantation. Int J Cardiol. 2014;174:624–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Poliacikova P, Cockburn J, de Belder A, et al. Antiplatelet and antithrombotic treatment after transcatheter aortic valve implantation—comparison of regimes. J Invasive Cardiol. 2013;25:544–8.PubMedGoogle Scholar
  12. 12.
    Durand E, Blanchard D, Chassaing S, et al. Comparison of two antiplatelet therapy strategies in patients undergoing transcatheter aortic valve implantation. Am J Cardiol. 2014;113:355–60.CrossRefPubMedGoogle Scholar
  13. 13.
    Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609–20.CrossRefPubMedGoogle Scholar
  14. 14.
    Bennett CL, Kim B, Zakarija A, et al. Two mechanistic pathways for thienopyridine-associated thrombotic thrombocytopenic purpura: a report from the SERF-TTP research group and the RADAR project. J Am Coll Cardiol. 2007;50:1138–43.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Shantsila E, Lip GYH, Chong BH. Heparin-induced thrombocytopenia. Chest. 2009;135:1651–64.CrossRefPubMedGoogle Scholar
  16. 16.
    Généreux P, Kodali SK, Green P, et al. Incidence and effect of acute kidney injury after transcatheter aortic valve replacement using the new valve academic research consortium criteria. Am J Cardiol. 2013;111:100–15.CrossRefPubMedGoogle Scholar
  17. 17.
    Briguori C, Colombo A, Violante A, et al. Standard vs double dose of N-acetylcysteine to prevent contrast agent associated nephrotoxicity. Eur Heart J. 2004;25:206–11.CrossRefPubMedGoogle Scholar
  18. 18.
    Birck R, Kzossok S, Markowetz F, et al. Acetylcysteine for prevention of contrast nephropathy: meta-analysis. Lancet. 2003;362:598–603.CrossRefPubMedGoogle Scholar
  19. 19.
    Barbanti M, Gulino S, Capranzano P, et al. Acute kidney injury with the RenalGuard System in patients undergoing transcatheter aortic valve replacement: The PROTECT-TAVI Trial (PROphylactic effecT of furosEmide-induCed diuresis with matched isotonic intravenous hydraTion in Transcatheter Aortic Valve Implantation). JACC Cardiovasc Interv. 2015;8:1595–604.CrossRefPubMedGoogle Scholar
  20. 20.
    Ussia GP, Scarabelli M, Mulè M, et al. Postprocedural management of patients after transcatheter aortic valve implantation procedure with self-expanding bioprosthesis. Catheter Cardiovasc Interv. 2010;76:757–66.CrossRefPubMedGoogle Scholar
  21. 21.
    Schaub F, Theiss W, Busch R, et al. Management of 219 consecutive cases of post-catheterization pseudoaneurysm. J Am Coll Cardiol. 1997;30:670–5.CrossRefPubMedGoogle Scholar
  22. 22.
    NHLBI balloon valvuloplasty registry participants. Percutaneous balloon aortic valvuloplasty. Acute and 30-day follow-up results in 67 patients from the NHLBI balloon valvuloplasty registry. Circulation. 1991;84:2383–97.Google Scholar
  23. 23.
    Otto CM, Mickel MC, Kennedy JW, et al. Three-year outcome after balloon aortic valvulo-plasty. Insights into prognosis of valvular aortic stenosis. Circulation. 1994;89:642–50.CrossRefPubMedGoogle Scholar
  24. 24.
    Piazza N, Onuma Y, Jesserun E, et al. Early and persistent intraventricular conduction abnormalities and requirements for pacemaking after percutaneous replacement of the aortic valve. JACC Cardiovasc Interv. 2008;1:310–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Sinhal A, Altwegg L, Pasupati S, et al. Atrioventricular block after transcatheter balloon expandable aortic valve implantation. JACC Cardiovasc Interv. 2008;1:305–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Limongelli G, Ducceschi V, D’Andrea A, et al. Risk factors for pacemaker implantation following aortic valve replacement: a single centre experience. Heart. 2003;89:901–4.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Koplan BA, Stevenson WG, Epstein LM, et al. Development and validation of a simple risk score to predict the need for permanent pacing after cardiac valve surgery. J Am Coll Cardiol. 2003;41:795–801.CrossRefPubMedGoogle Scholar
  28. 28.
    Fraccaro C, Buja G, Tarantini G, et al. Incidence, predictors, and outcome of conduction disorders after transcatheter self-expandable aortic valve implantation. Am J Cardiol. 2011;107:747–54.CrossRefPubMedGoogle Scholar
  29. 29.
    Calvi V, Puzzangara E, Pruiti GP, et al. Early conduction disorders following percutaneous aortic valve replacement. Pacing Clin Electrophysiol. 2009;32:126–30.CrossRefGoogle Scholar
  30. 30.
    Jilaihawi H, Chin D, Vasa-Nicotera M, et al. Predictors for permanent pacemaker requirement after transcatheter aortic valve implantation with the CoreValve bioprosthesis. Am Heart J. 2009;157:860–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Khawaya MZ, Rajani R, Cook A, et al. Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve collaborative). Circulation. 2011;123:951–60.CrossRefGoogle Scholar
  32. 32.
    De Jaegere PP, Piazza N, Galema TW, et al. Early echocardiographic evaluation following percutaneous implantation with the self-expanding CoreValve revalving system aortic valve bioprosthesis. EuroIntervention. 2008;4:351–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Piazza N, Schultz C, De Jaegere PP, et al. Implantation of two self-expanding aortic bioprosthetic valves during the same procedure insights into valve-in-valve implantation (“Russian doll concept”). Catheter Cardiovasc Interv. 2009;73:530–9.Google Scholar
  34. 34.
    Barbanti M, Capranzano P, Ohno Y, et al. Early discharge after transfemoral transcatheter aortic valve implantation. Heart. 2015;101:1485–90.CrossRefPubMedGoogle Scholar
  35. 35.
    Butchart EG, Gohlke-Bärwolf C, Antunes MJ, et al. Working groups on valvular heart disease, thrombosis, cardiac rehabilitation, exercise physiology and European Society of Cardiology. Recommendations for the management of patients after heart valve surgery. Eur Heart J. 2005;26:2463–71.Google Scholar
  36. 36.
    Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: the Task Force on the management of valvular heart disease of the European Society of Cardiology. Eur Heart J. 2007;28:230–68.PubMedGoogle Scholar
  37. 37.
    Montorsi P, De Bernardi F, Muratori M, et al. Role of cine fluoroscopy, transthoracic and TEE in patients with suspected prosthetic valve thrombosis. Am J Cardiol. 2000;85:58–64.CrossRefPubMedGoogle Scholar
  38. 38.
    Webb JG, Altwegg L, Boone RH, et al. Transcatheter aortic valve implantation: impact on clinical and valve-related outcomes. Circulation. 2009;119:3009–16.CrossRefPubMedGoogle Scholar
  39. 39.
    Gotzmann M, Mügge A. Fatal prosthetic valve endocarditis of the CoreValve ReValving System. Clin Res Cardiol. 2011;100:715–7.CrossRefPubMedGoogle Scholar
  40. 40.
    Carnero-Alcázar M, Maroto Castellanos LC, Camicer JC, et al. Transapical aortic valve prosthetic endocarditis. Interact Cardiovasc Thorac Surg. 2010;11:252–3.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Cardiovascular DepartmentFerrarotto Hospital, University of CataniaCataniaItaly

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