Do you recommend routine use of protamine for hemostasis at the end of a transfemoral TAVI?

Always, in order to guarantee hemostasis of the femoral site and minimize femoral access complications. Dose is weight based, anegdotically lots of institutions give half the recommended dose as they still see some of the positive effects. Warning: ask about history of allergy/anaphylaxis. Protramine is a fish derivative (from the salmon’s pituitary gland), so cross allergies may be a consideration as well.

There is an incidence of anaphylaxis in 1-2 %. Therefore, I give it if I have continued oozing or bleeding from the groin rather than routinely. I had witnessed a case of sudden ST elevation that corresponded with quick infusion of Protamine, and immediate angiography showed diffuse coronary spasm that was relieved with recurrent IC NTG. Although the classical teaching of 1 mg per 100 units of heparin seems overkill in my experience and 0.5mg or less per 100 unit of heparin is more appropriate.

The practice of protamine post TAVI is a remnant of an era of > 18 Fr sheaths, with ‘up and over’ PTA-assisted closure, and vascular event rates > 5%.

We don’t use protamine after CHIP, and the IMPELLA CP device goes through a 14 Fr sheath, not very dissimilar to current-generation TAVI sheaths. Closure techniques have also improved, and MANTA as the newest closure device, has helped optimize access site closure.

While protamine is still administered (at a lower dose of 0.5 mg or less per 100 U of heparin), it is usually reserved for cases with suboptimal femoral access site closure.