**11.3 Point-guard system™ dynamic cerebral embolic protection (Transverse Medical, Inc, Denver, CO, USA)**

This device has a filter mesh in a flexible nitinol frame that can cover all the major branches of the aortic arch. This is stabilized during positioning through its isolation zone. Currently this system is not widely available for use as there is not enough clinical data. The CENTER trial will be initiated to evaluate this system [59].

### **11.4 Emblok embolic protection system (Innovatice Cardiovascular Solutions, Grand Rapids, MI, USA)**

This system not only offers cerebral protection during TAVR but also protects the abdominal and peripheral vasculature. The device can be implanted through an 11- French transfemoral sheath with a pigtail catheter and is then advanced into the aorta. This device was studied and proven to have successful deployment. The study noted that no cerebrovascular or cardiovascular events were seen at 30 days follow-up. However further studies need to be done to see improvement in clinical outcomes using this device [59].

Overall, the introduction of CEPD was done in order to help lower the risk of stroke after the TAVR procedure and to help prevent cerebral embolization. However, in studies involving CEPD, there has not been a significant reduction noticed in stroke rate. This could be seen due to limiting number of studies and sample size used. The PROTECTED TAVR trial had a 95% confidence interval therefore it did not rule out the overall benefit of the use of CEP in TAVR procedure [60]. Nevertheless, CEPD may be an asset in the future for cerebral embolic protection with technical improvements.

#### **12. Post-procedure management**

Post TAVR care includes routine follow-up clinically. This includes getting an echocardiogram prior to discharge, at 1 month follow-up, then at 6–12 months, and followed by annually. Echocardiogram is used to watch for long term complications as well as assess the transvalvular gradient over time.

#### **12.1 Antithrombotic treatment**

Antithrombotic therapy post TAVR depends on a few factors such as the simultaneous indication of antiplatelet therapy (history of recent coronary artery stent

placement) and/or the simultaneous indication of anticoagulation (history of atrial fibrillation). Regardless it is important for patients to be on antithrombotic therapy at least for the first 3–6 months following the procedure.

For patients without a simultaneous indication of antiplatelet therapy or dual antiplatelet therapy (DAPT), it is recommended to treat with a single antiplatelet therapy (SAPT) for life. Typically, this includes Aspirin 75–100 mg daily. If aspirin is contraindicated for the patient, the alternative is clopidogrel (Plavix) 75 mg daily.

For patients with no indication of anticoagulation, it is recommended to be on DAPT with Aspirin and Plavix during the first 3–6 months (depending on valve type). Then followed by lifelong SAPT.

For patients with a simultaneous indication of dual antiplatelet therapy such that they had a recent coronary artery stenting, the duration of DAPT and the specific agents depends on the concurrent indication. After that period, it is recommended to continue with daily SAPT for life rather than anticoagulation.

Generally triple antithrombotic therapy (anticoagulation and DAPT) is typically avoided due to increase bleeding risks [61].

#### **12.2 Endocarditis prophylaxis**

Patients with prosthetic valves are at high risk for endocarditis. Rates are the highest during the first year of placement and then decrease over time. Therefore, it is vital to properly educate patients about infective endocarditis. This includes discussing the importance of regular dental care and antimicrobial prophylaxis before procedures that may lead to bacteremia. Recommended prophylaxis for penicillin tolerant and penicillin allergic patients included Amoxicillin and Clindamycin, respectively [62].

#### **12.3 Durability of valves at 5–10 years**

There are not many studies completed so far that show data regarding the longterm durability of the valve. In a study completed in the UK, using the UK TAVR registry, looked into patients who underwent TAVR over a span of 5 years. The study had 241 patients with 149 patients having the self-expandable valve and 80 patients with a balloon-expandable valve. The patients were evaluated post-procedure and echocardiographic follow-up ranging from 5 to 10 years. Most of the patients had none to trivial aortic regurgitation at follow-up. This study concluded that 91% of the patients did not have structural valve degeneration at 5 and 10 years post- TAVR follow up [63]. The NOTION trial spans over 10 years and is the longest clinical trial comparing randomized patients undergoing a TAVR versus SAVR. It was completed in Denmark and Sweden and enrolled patients between 2009 and 2013. The study shows patients who had a TAVR procedure had comparable risk for all-cause mortality, myocardial infarction, and stroke as patients who had a SAVR completed.

#### **12.4 Redo TAVR (ViV TAVR)**

Failed TAVRs can be challenging to approach and involve many factors to consider such as patient's advancing age, co-morbidities, transcatheter heart valve (THV) design, and tissue ingrowth. Late degeneration of THVs in patients will likely increase in the future therefore it is vital to know how to fix this issue. Redo TAVR has shown to be an effective and safe treatment in these situations [64].
