Our study population consisted of 146 patients with a diagnosis of aortic stenosis and an ED presentation within 30 days of their TAVR procedure. The demographics of our study were made up of mostly geriatric patients with an average age of 79.7 (median 79.7 years, interquartile range 72.5–86.6). Male patients made up a larger portion of the study population at 61% compared to the female patients at 39%.

Among our 146 patients, there was a collective total of 168 ED visits within 30 days of the TAVR procedure. 124 patients (85%) visited the ED once and 22 (15%) visited the ED twice within this time frame. Among these 168 total ED visits, 117 (70%) resulted in admission to an inpatient service. The median time from the TAVR procedure to ED presentation was 12 days, with a range of 2 to 30 days and an interquartile range of 6 to 21 days. The median length of hospital stay upon ED presentation was 2 days, with a range of 0 to 34 days and an interquartile range of 0 to 4 days. Of all patients who presented to the ED, 7 (4.8%) passed away during their hospital stay (Table 1).

The common presenting complaints were respiratory symptoms, mentioned in 45 of the 168 total visits (27%), most notably dyspnea (n = 43) followed by cough (n = 3). Thereafter, neurological symptoms were reported in 38 instances, comprising 23% of all visits. Common neurologically related complaints encompassed falls (n = 15), syncope (n = 8), dizziness (n = 7), altered mental status (n = 7), and lightheadedness (n = 7). Cardiovascular symptoms, reported in 30 cases, ranked third and made up 18% of visits. Within this category, chest pain was the predominant presenting symptom (n = 21), followed by palpitations (n = 4). Additional presenting symptoms included vascular complaints in 26 patients (15%), abdominal symptoms in 24 patients (14%), constitutional symptoms in 22 patients (13%), and access-related symptoms in 15 patients (9%) (Table 2).

On chart review, the most commonly cited indications for imaging during the ED visit or during their subsequent readmission included dyspnea, fall, chest pain, head injury/ trauma and syncope. Neurologic indications for imaging were the most common in this population (n = 52) followed by vascular indications (n = 37) and cardiac indications (n = 25) (Table 3). While never mentioned as a sole indication for cross-sectional imaging, post-TAVR status was often included alongside other indications.

A total of 250 cross-sectional imaging examinations were obtained across all ED visits for the included 146 patients, with an average of 1.7 examinations per patient (Table 4). The most common imaging modality utilized was CTs (n = 129). CT examinations ordered include CT head (n = 39), CTA Chest (n = 26) CT abdomen and pelvis (A/P) with contrast (n = 16), CT chest without contrast (n = 24) and C-spine without contrast [11]. Ultrasounds were the second most common type of cross-sectional imaging ordered (n = 101). The 2 most common ultrasound modalities were echocardiograms (n = 47) and duplex extremity vasculature ultrasounds (n = 40). Other modalities also include MRI brain (n = 12), nuclear imaging (n = 7), and fluoroscopy (n = 1).

There were 47 acute findings overall from the imaging that were obtained. Of note, 3 patients had 2 acute findings each. In total, 44 of the 146 patients (30.1%) were found to have acute findings.

Common imaging findings from chest imaging included 7 cases of pneumonia and 4 pleural effusions. Presenting symptoms varied widely from patient to patient for pneumonia, with no clear trend (Fig. 2). The most common presenting symptom was shortness of breath for patients with pleural effusions, present in 4 of 5 patients (Fig. 3). Of note, 1 case of pleural effusion was found on abdominal imaging.

75 year old female with history of hyperlipidemia presenting with nausea and generalized weakness. Axial CT images in lung window demonstrate bilateral multifocal nodular and patchy ground-glass opacities consistent with infectious pneumonia

84 year old female with history of Monckeberg’s arteriosclerosis presenting with shortness of breath. Axial CT images in lung window shows (A) pleural effusion (orange arrow) and (B) interlobular septal thickening and ground glass opacities (blue arrows) representing pulmonary edema

Head and neck imaging findings included 4 cases of stroke and 1 brain hematoma. Altered mental status was the predominant presenting symptom, which was found in 4 of 5 patients (Figs. 4 and 5).

71 year old with a history of pernicious anemia. Presenting with fatigue and left sided temporal headache. Axial Diffusion weighted (DWI) MRI imaging of the brain demonstrates small focus of restricted diffusion in left frontal lobe consistent with acute or subacute infarct

81 year old female with a history of peripheral vascular disease presenting with toe pain in bilateral feet. (A) Axial CT head 26 days prior to ED visit demonstrating loss of gray-white differentiation in the medial left occipital lobe, consistent with acute to subacute left PCA territory infarction. (B) On presentation Axial CT head demonstrates evolution of a left occipital subacute infarction, larger and more discrete appearing than previously, also now with petechial hemorrhage

When it came to abdominal imaging, these included 1 gastrointestinal bleed and 4 access site complications: 1 access site hematoma, 1 case of necrotizing fasciitis (Figs. 6), 1 pseudoaneurysm (Figs. 7) and 1 femoral artery thrombus. Most commonly, these patients reported some form of localized groin (swelling, infection, bleeding) or leg symptoms (leg pain, swelling). However, some presented with non-specific signs such as GI discomfort (abdominal pain, nausea, vomiting, diarrhea) or weakness. Of note, 1 case of pneumonia was also found on abdominal imaging.

69 year old female presenting with infected groin wound. Axial CT images of the pelvis in soft tissue window demonstrate (A) fat stranding and foci of air in the left lower abdominal wall, demonstrating necrotizing fasciitis. (B) Post treatment CT pelvis in soft tissue window resolution of necrotizing fasciitis status-post debridement and repair of the left inguinal area

88 year old male with history of cerebral vascular accident presenting with nausea and vomiting. CT abdomen and pelvis in soft tissue window in Axial (A) and sagittal (B) reformats demonstrate a 1.4 cm hyperdensity (blue arrow) anteriorly at the left common femoral artery, most consistent with a pseudoaneurysm and heterogeneous density surrounding left common femoral vessels, suggestive of hematoma

The most common imaging finding from cardiac imaging (ECHO) was heart failure. There were 8 total cases in this population. The most common patient presentation was shortness of breath, which was found in 5 of 8 patients. Other presenting symptoms included hypotension, fatigue, abnormal ICD firing, chest pain, and hyponatremia.

In imaging of the extremities such as duplex ultrasounds (n = 40) and extremity MRI (n = 1), common imaging findings include 1 deep vein thrombosis and 4 access site complications: 3 cases of access site hematoma and one access site thrombus. These patients commonly presented with localized leg swelling or pain.

Ultimately, while echocardiograms and duplex extremity vasculature ultrasounds were the most abundant types of studies ordered with 47 and 40 studies respectively, CTA chest and echocardiograms were the 2 study modalities that most commonly resulted in acute findings of significance with 12 and 8 findings respectively (Table 5).