Streamlining peri-procedural pathways is a cornerstone of modern interventional cardiology, reducing length of hospital stay, decreasing healthcare costs and avoiding unnecessary risks for patients. Intensive care unit (ICU) admission following transcatheter edge-to-edge mitral valve repair (M-TEER) has been the standard post-procedural track at our center among others. However, due to the massive decrease of ICU capacities during the COVID-19 pandemic our center established primary admission to a cardiologic general care unit after M-TEER. This study evaluated the risks and benefits of reduced post-procedural monitoring. 

 

We examined 624 consecutive patients who underwent M-TEER under general anesthesia at our center from March 2017 to February 2023. The first 312 patients were admitted to the ICU following the procedure. The following 312 patients were admitted primarily to a cardiologic general care unit (monitoring unit, MU). Monitoring comprised continuous recording of ECG recording and peripheral oxygen saturation as well as periodical non-invasive blood pressure measurements. A physician was available 24 hours. We compared both patient cohorts, assessed in-hospital complications and predictors of unplanned ICU admission. 

 

Patients admitted to the MU had lower baseline mitral regurgitation (MR) grade compared to the ICU group (70.5 vs. 78.2% with MR grade IV, p = 0.04) and post-procedural MR reduction was more significant in these patients (p < 0.001). Patients admitted to the MU spent less time in the hospital (median 6.0 days vs. 7.0 days, p < 0.001). They also had lower risk for in-hospital complications such as infections (2.9 vs. 7.7%, p = 0.008) and delirium (0.6 vs. 2.6%, p = 0.056). In-hospital mortality was similar in both groups (0.6% in the MU group, 1.3% in the ICU group, p = 0.41). 50 patients (16.0%) that were planned to be admitted to the MU were instead treated on the ICU. Most frequent indications for unplanned ICU admittance was prolonged need for catecholamines (52.0%) and prolonged mechanical ventilation (32.0%). Patients with unplanned relocation to the ICU were younger (median 76.5 years vs. 81.0 years, p = 0.009), more often male (66.0 vs. 50.8%, p = 0.048) and had more advanced heart failure: left-ventricular (LV) ejection fraction < 30% in 36.0 vs. 16.0% (p = 0.001), NYHA functional class IV in 24.0 vs. 12.6% (p = 0.037), severe concomitant tricuspid regurgitation in 48.0 vs. 28.2% (p = 0.006), larger LV end-diastolic diameters (median 62.0 mm vs. 56.0 mm, p = 0.011) and higher NT-proBNP (median 4671.0 pg/ml vs. 2140.0 pg/ml, p < 0.001). No significant difference in post-procedural MR grade was seen in these patients (p = 0.29). In-hospital mortality in patients with unplanned ICU admission was 4.0% while it was 0% in patients not requiring ICU treatment (p = 0.001). After adjustment for covariates and correlation, LV ejection fraction of < 30% was an independent predictor of unplanned ICU admission (Odds Ratio 3.045 (95% confidence interval 1.545 – 6.003), p = 0.001). 

 

Post-procedural admittance of M-TEER patients to a general care unit instead of primary ICU relocation leads to shorter hospital stay and lower risk for in-hospital complications without compromising patient safety. Patients with advanced heart failure however have an increased risk for unplanned ICU treatment and an LV-EF of < 30% is an independent predictor of ICU admittance after M-TEER.