How Safe Are Current Expert Consensus Recommendations For Discharge After Tavi?

Abstract Introduction How long patients (pts) remain at risk to develop conduction abnormalities (CAs) requiring pacemaker (PM) implantation after transcatheter aortic valve implantation (TAVI) and should therefore be monitored remains controversial. A recently published Expert Consensus Document (CD) proposes an ECG-based algorithm to risk-stratify patients and suggests early discharge of patients with low risk. Our institutional policy is to monitor all patients without previous PM for at least 7 days. We aimed to apply the discharge recommendations of this algorithm retrospectively to our patient cohort with prolonged and well documented ECG monitoring post-TAVI to evaluate the safety of this strategy. Methods We studied the development CAs in 1447 consecutive patients treated with Sapien 3 between January 2014 and December 2019. After excluding valve-in-valve procedures (n=30) and pts with previously implanted PM (n=167) 1254 remained for this analysis. Results Of 1254 pts, 159 (12.7%) developed high grade CAs requiring PM implantation after TAVI. 808 (64%) had no pre-existing right bundle branch block (RBBB) and no ECG changes immediately post-procedure (CD Group 1, hospital discharge recommended at day 1 post TAVI). Of these pts, 50 (6%) developed high grade CAs within the first 24 hours (h) after TAVI but 31 (3.8% of Group 1) after 24h (Figure 1, Panel A). 111 (8.9%) pts had pre-existing RBBB and no new ECG changes after TAVI (CD Group 2, hospital discharge recommended at day 2 post TAVI). In this group 27 pts (24%) developed high grade CAs within the first 48h after TAVI but 14 (12.6%) after 48h (Figure 1, Panel B). 62 pts had pre-existing CAs and had ECG-changes (CD Group 3, hospital discharge recommended at day 2 post TAVI if no progression). In this group 9 (14%) developed high grade CAs within the first 48h after TAVI but 5 (8%) after 48h (Figure 1, Panel C). 212 (17%) patients had a new-onset left bundle branch block (LBBB) after TAVI (CD Group 4, hospital discharge recommended at day 2 post TAVI if resolution/no progression); of these pts, 7 (3.3%) developed high grade CAs within the first 48h after TAVI and 13 (6.1%) after 48h (Figure 1, Panel D). Conclusion In this large TAVI cohort with a PM implantation rate of 12.7%, 40% of pts (5% of the entire population) would have been already discharged at the time they developed their CA when following recently published expert consensus recommendations. These results question the safety of the recommended early discharge algorithm and support a more conservative strategy. Figure 1 Funding Acknowledgement Type of funding source: None