Direct Admission of Selected Patients to Intermediate Cardiology Unit after TAVI is Feasible and Safe

Background: Transcatheter aortic valve implantation (TAVI) volumes increase rapidly as the procedure is performed in lower risk patients. Common practice is to observe TAVI patients at least for 24 hours in intensive care unit (ICU) to monitor for possible post procedural complications. This practice poses increasing burden on ICU staff and bed availability.

Aim: To assess safety of admitting post-TAVI patients directly to intermediate cardiology unit (INTER) following the procedure.

Methods: Between Nov 2016 to Aug 2018 in sheba medical center, 98 patients underwent transfemoral TAVI were admitted directly to INTER after 2-hour observation in cath-lab recovery room. Criteria to qualify patients for direct INTER was: normal QRS complex on baseline ECG or paced rhythm, no new conduction abnormality immediately following TAVI, hemodynamic stable patient, no valve related or neurologic complication. Baseline characteristics, procedural, in hospital and long-term outcome were recorded. Furthermore, analysis of propensity score matched data from the same center in 1:4 ratio was conducted conducted for further comparison of short and long-term outcomes.

Results: 98 patients were admitted directly to INTER. Compared to ICU patients, INTER patients were of the younger (average 82 years vs 85.1, p<0.001), half of them males (50% vs 46%, p=0.58). INTER patients had lower EuroSCORE II (3.9 vs. 5.2%, P=0.05) and found to be pacemaker carriers (20% vs 9%, p<0.001). Balloon expandable valve was implanted in 34% of the INTER patients compared to 43% in the ICU group (p=0.08). In terms of complications, in-hospital stroke 2% vs 3.1% (p=0.78), new atrial fibrillation episodes 4.5% vs. 9.9% (p=0.14), major bleeding (0% vs 3.7%, p=0.06) and new permanent pacemaker implantation 8% vs. 18.8% (p=0.017). Hospitalization duration was significantly shorter for INTER patients (6.11±5.74 vs. 11.14 ±17.86 days, p=0.006). In hospital mortality for INTER patients was 1% vs 4%, p=0.006). when compared with propensity score matched subjects in ratio 1:4, in-hospital mortality was non-significantly lower in INTER (1.3% vs 4.3% p=0.4) and a trend toward a less pacemaker implantation in INTER (6.9% vs 16.3%, p=0.06) was noted. mean hospitalization days was significantly lower in INTER (5.8±4.9vs 10.2±16.4, p=0.02).

Conclusions: Initial experience with structured criteria to identify low risk patients is effective and safe for selecting patients for direct admission to an intermediate cardiology unit immediately after TAVI.