Clin Res Cardiol (2022).

A reduced postprocedural monitoring concept after transcatheter aortic valve implantation is feasible and safe compared to a standardized postprocedural intensive care monitoring
B. Gonska1, H. Kirindi1, T. Stephan1, J. Mörike1, C. Buck1, W. Rottbauer1, D. Buckert1
1Klinik für Innere Medizin II, Universitätsklinikum Ulm, Ulm;
Background: The postprocedural care pathway after transcatheter aortic valve implantation (TAVI) mostly consists of monitoring on an intensive care unit (ICU) for 24 to 48 hours. When the still ongoing COVID-19-pandemic reduced intensive care capacities to the disadvantage of cardiovascular patients, our center established a dedicated monitoring unit for postprocedural care of TAVI patients to reduce the stress on the remaining intensive care capacities.

Objective: The aim of this study was to evaluate the in-hospital outcome of patients before and after the change in postprocedural care pathway in order to generate an optimized postprocedural monitoring standard after TAVI.

Methods and Results:
Starting in April 2020 a monitoring unit was established for the postprocedural care of TAVI patients. The unit consisted of central monitoring of ECG, non-invasive blood pressure and oxygen saturation, furthermore 24-hour physician presence. TAVI patients with clinically relevant hemodynamical, respiratory or neurological conditions were still transferred to the ICU directly postprocedural. This study evaluated the cohorts of patients treated with TAVI before and after the change in monitoring concept concerning postprocedural in-hospital complications (defined as rhythm disorders/pacemaker implantation >24 hours after TAVI, infection treated with i.v. antibiotics, myocardial infarction, resuscitation, death, delirium, Stroke, acute kidney injury, major bleeding, major vascular complications, heart failure). 
796 patients treated with TAVI at our center were included. 150 patients (18.8%) were transferred to the monitoring unit after the change of postprocedural care pathway. 504 patients (63.3%) had been transferred to the ICU due to the prior existing pathway and 142 patients of the overall cohort (17.8%) were transferred to the ICU due to clinical indications (rhythm disorders:n=74 (9.3%);hemodynamic instability:n=29 (3.6%);assist device:n=6 (0.8%);major vascular complications:n=11 (1.4%);neurological reasons:n=8 (1.0%);respiratory insufficiency:n=11 (1.4%);periinterventional PCI:n=2 (0.3%)). In-hospital complications occurred in 26 patients transferred to the monitoring unit (17.3%), mostly rhythm disorders leading to pacemaker implantation (n=16, 61.5%), one patient died (0.04%). In the group of patients transferred to the ICU without further clinical indication due to the prior postprocedural pathway 123 patients (24.4%) experienced in-hospital complications, such as rhythm disorders (n=44, 35.8%), infections treated with i.v. antibiotics (n=23, 18.7%), delirium (n=34, 27.6%), in this cohort also one patient died (0.01%). Therefore, there was a relevant numerical, though not statistically significant difference in in-hospital complications between both groups (17.3% vs. 24.4%, p=0.07). Independent predictors for a complicated in-hospital postprocedural stay of the overall study population were preprocedural severity of NYHA class (p=0.04), elevated NTproBNP (p=0.02) as well as presence of chronic lung disease (p=0.0003) or anemia (p=0.01). 

 After TAVI in approximately 20% of patients there is need for postprocedural intensive care monitoring. In the remaining patients a reduced postprocedural monitoring concept is feasible and safe and might even be of advantage concerning in-hospital complications such as infections or delirium to a postprocedural intensive care monitoring without further indication for the ICU.