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cardio.cardiac-tamponade.post-tavr.v1

Cardiac tamponade — post-TAVR (transcatheter aortic valve replacement)

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Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to post-TAVR mechanisms per VARC-3 (Généreux JACC 2021 PMID 34304871): catheter/wire perforation of LV apex (most common, ~40-50% of post-TAVR tamponade per Yashima JACC Cardiovasc Interv 2017), RV free-wall perforation by temporary pacing wire, annulus rupture with extravasation (Pasic JACC 2015; ≈1% of TAVR; balloon-expandable + oversized + calcified = highest risk), valve embolization with aortic dissection, coronary occlusion (LM or ostial RCA per Ribeiro JACC 2013) with secondary effusion. Incidence 1-3% TAVR procedures; mortality if untreated >50%; with prompt drainage + surgical backup ≈10-20%. Specializes parent for: STAT TEE in TAVR suite (perforation site + tamponade physiology + valve seating + AR severity); fluoroscopic aortogram for annulus rupture identification; protamine reversal of procedural UFH (typical 30-50 mg given ACT 250-300 procedural target); reversal of pre-procedural warfarin/DOAC (idarucizumab per RE-VERSE AD PMID 28793172, andexanet per ANNEXA-4 PMID 30730782); SIMULTANEOUS cardiac surgery activation for annulus rupture (mortality 50-70% even with surgery per Pasic 2015), persistent bleeding, valve embolization; covered stent for accessible coronary perforation (Holmes JACC 2011); post-procedure SAPT per POPULAR-TAVI (PMID 32865375) unless AF requires AC; conduction monitoring for new LBBB / complete heart block requiring permanent pacemaker (PARTNER guidance); annual echo surveillance for valve function/gradient/PVL/AR per VARC-3 + Otto 2021 (PMID 33342586). Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (TAVR-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated reversal-agent codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute (Phase E wave 13).

Entry points (4)

  • history
    Intra-procedural hypotension/bradycardia/arrest in TAVR suite during catheter manipulation, balloon valvuloplasty, valve deployment, or temporary pacing — STAT TEE for perforation site (VARC-3 PMID 34304871)
    intra_procedural_decompensation_during_tavr
  • history
    Post-TAVR hemodynamic decompensation within first 24h post-procedure → late perforation or annulus rupture extravasation (Yashima JACC Cardiovasc Interv 2017)
    post_tavr_decompensation_in_first_24h
  • imaging
    New pericardial effusion on intra-procedural TEE or immediate post-TAVR echo (VARC-3 PMID 34304871)
    tee_new_pericardial_effusion_intra_or_post_tavr
  • history
    Annulus rupture with contrast extravasation visualized on completion aortogram — life-threatening; immediate cardiac surgery activation (Pasic JACC 2015)
    annulus_rupture_with_contrast_extravasation_on_aortogram

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    TAVR population is older (median 82); higher complication risk + worse outcomes (PARTNER trials)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is part of Beck triad; rapid accumulation in TAVR setting produces tamponade at small volumes (Spodick Circulation 2003)
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachycardia in tamponade physiology; or pacing-dependent bradycardia post-TAVR (ESC 2015)
  • teerequired
    imaging • used at INITIAL_WORKUP
    STAT TEE in TAVR suite — perforation site localization (LV apex vs RV free-wall vs annulus) + tamponade physiology + valve seating + AR severity (VARC-3 PMID 34304871; ESC 2015 Class I)
  • fluoroscopy_perforation_localizationrequired
    imaging • used at INITIAL_WORKUP
    Fluoroscopic identification of guidewire/catheter position at perforation site; aortogram for annulus rupture identification (Yashima 2017)
  • procedural_anticoagulation_statusrequired
    history • used at CONTEXT
    TAVR uses procedural UFH (ACT 250-300); reversal with protamine drives bleeding control (VARC-3; Bhatt 2018)
  • pre_procedural_anticoagulationrequired
    history • used at CONTEXT
    Many TAVR patients on warfarin/DOAC for AF — pre-procedure status drives reversal strategy (Bhatt Circulation 2018)
  • hemoglobinrequired
    lab • used at INITIAL_WORKUP
    Hemorrhagic loss quantification + transfusion threshold (ESC 2015)
  • inrrequired
    lab • used at INITIAL_WORKUP
    Coagulopathy quantification for warfarin reversal (Bhatt 2018)
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy risk + DOAC dose-reduction; KDIGO 2021 race-free eGFR (Inker NEJM 2021)

12-phase flow (9)

  1. 1FRAME
    Post-TAVR tamponade — emergent pericardiocentesis + STAT TEE for perforation site + simultaneous cardiac surgery activation (VARC-3 PMID 34304871; ESC 2015 §Iatrogenic)
    inputs: sbp
    advance: TAVR-context tamponade physiology suspected
  2. 2ENTRY
    Recognize intra-procedural decompensation in TAVR suite OR within 24h post-procedure; activate cardiac surgery EARLY for annulus rupture (Pasic JACC 2015)
    inputs: age
    advance: TAVR-context decompensation confirmed
  3. 3CONTEXT
    Document TAVR specifics: valve type (balloon vs self-expanding), valve size, annulus measurements, pre/intra-procedural anticoagulation, comorbidities (frailty, prior cardiac surgery, AS severity); drives surgical approach + reversal (VARC-3)
    inputs: procedural_anticoagulation_status, pre_procedural_anticoagulation
    advance: TAVR context fully captured
  4. 4RED_FLAGS
    Obstructive shock physiology in elderly frail TAVR population — low physiologic reserve; rapid arrest possible (Spodick 2003); annulus rupture = immediate surgical mortality if not corrected (Pasic 2015)
    inputs: sbp, hr
    advance: shock recognized → emergent drainage prepared with cardiac surgery active
  5. 5INITIAL_WORKUP
    STAT TEE (perforation site + tamponade physiology + valve seating + AR), fluoroscopy/aortogram, ECG, troponin, BMP, type & cross 4 units PRBC, coags (PT/INR, aPTT, fibrinogen, anti-Xa if DOAC), CBC; coronary angiography if coronary occlusion suspected (VARC-3; Holmes 2011)
    inputs: tee, fluoroscopy_perforation_localization, inr, hemoglobin, creatinine
    actions: panel.cardiac, panel.coag, panel.cbc
    advance: TEE confirms tamponade physiology + perforation site identified + bleeding burden quantified
  6. 6DIFFERENTIAL
    Identify mechanism: LV apex perforation (stiff wire), RV free-wall perforation (pacing wire), annulus rupture (oversizing/calcification), valve embolization with dissection, coronary occlusion (LM, ostial RCA) with secondary effusion (Yashima 2017; Pasic 2015; Ribeiro JACC 2013 coronary obstruction)
    advance: mechanism identified or actively investigated
  7. 7TREATMENT
    Step 1 emergent pericardiocentesis (echo or fluoroscopic-guided); Step 2 protamine reversal of procedural UFH + reversal of pre-procedural AC; Step 3 emergent cardiac surgery for: annulus rupture, persistent bleeding, valve embolization with dissection, LV apex perforation with persistent bleeding; Step 4 covered stent for accessible coronary perforation (Holmes JACC 2011); Step 5 PCI/CABG for coronary occlusion (Ribeiro 2013) (VARC-3; ESC 2015 §Iatrogenic; Bhatt 2018)
    inputs: sbp
    advance: drainage performed + reversal initiated + surgical/interventional disposition determined
  8. 8DISPOSITION
    CCU/ICU post-drain; cardiothoracic surgery direct from TAVR suite if annulus rupture or persistent bleeding; cardiac catheterization lab for covered stent if coronary perforation accessible (VARC-3)
    advance: multidisciplinary disposition confirmed
  9. 9MONITORING
    Re-accumulation surveillance (TEE/TTE q4-6h × 24h then q12-24h × 48h); serial Hb; coagulation correction tracking; valve function reassessment; conduction monitoring (TAVR commonly causes new LBBB / heart block requiring permanent pacemaker)
    actions: panel.pleural
    advance: bleeding controlled + no re-accumulation × 48h + valve function confirmed