How to minimize bleeding risks after TAVR
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Bleeding events remain a serious, potentially fatal complication of transcatheter aortic valve replacement (TAVR). By identifying high-risk patients early and embracing a variety of preventive measures, however, care teams can work toward keeping these events to a minimum.
That is all according to a new analysis published in the Journal of Clinical Medicine.[1]
“Although significant advances in the technology and techniques of TAVR—such as the use of smaller and more hydrophilic slippery sheaths, the widespread adoption of ultrasound-guided femoral access and the selection of lower-risk patients—have been adapted over the last few years, a substantial percentage of patients develop clinically relevant bleeding after the procedure,” wrote first author Iosif Xenogiannis, MD, a cardiologist with Mitera General Hospital in Athens, Greece, and colleagues. "In the early era of TAVR, it was estimated that 14.7–46.2% of patients experienced major, life-threatening, or disabling bleeding at one year after the procedure. More recently, this rate has decreased to 3.2–13.1%, which, although significantly lower, remains noteworthy.”
Xenogiannis et al. emphasized that knowing more the about patient-related factors associated with bleeding after TAVR can help care teams reduce risks. For example, they wrote, multiple studies have suggested women and patients with chronic kidney disease face an increased likelihood of bleeding following treatment. Also, in-hospital and one-year bleeding risks have been found to be higher among patients with peripheral artery disease.
Another key takeaway from the analysis was the fact that ultrasound-guided arterial puncture is being used more often to help care teams gain femoral access during TAVR. This has been found time and time again to reduce the risk of bleeding and vascular complications.
When femoral access is not available, the authors added, it may increase the risk of bleeding—but techniques and technologies have evolved enough over time to make other access options more safe.
“During the TAVR procedure, the femoral artery should be the access site of choice, followed by transcarotid, transaxillary/subclavian, and transcaval access, preferably in centers with substantial experience in gaining access through alternative access sites, with transaortic and transapical access being the least preferable options,” the authors wrote. “The radial artery is highly recommended as the default secondary arterial access, whereas in centers with significant experience and with the use of balloon-expandable valves, a single arterial access for the entire TAVR procedure seems to be a favorable strategy for preventing bleeding complications.”
Xenogiannis and colleagues also pointed to two bleeding risk scores, PREDICT-TAVR and a recent proposal from the Valve Academic Research Consortium for High Bleeding Risk (VARC-HBR), as helpful tools that can predict when patients may face a heightened risk of adverse bleeding after TAVR. While PREDICT-TAVR is a six-item score, the new VARC-HBR model includes 21 criteria in all.
Cardiologists can also help combat the risk of post-TAVR bleeding events by ensuring the patient is on the appropriate antithrombotic regimen; single antiplatelet therapy with aspirin is a common go-to strategy. Planning ahead with medical imaging is also a critical step—the authors point to pre-procedural CT scans as “the undisputed standard of care, providing an essential roadmap for the heart tam to plan and execute the procedure with an enhanced safety and precision.” The CT results can then be helped to ensure the proper valve is chosen.
Finally, the team behind this analysis wrote that monitoring a patient closely following TAVR is essential.
“Given the high rate of late bleeding events, patient monitoring for bleeding should not stop with their discharge from the hospital after a successful TAVR operation, but rather, it must continue—ideally indefinitely,” they wrote.
Click here to read the full analysis.
Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.