Improving care pathways: Permanent Pacemaker Insertion after TAVI

24th March 2021

An advisory board was held in March 2020: TAVI experts came together to evaluate the treatment pathway for TAVI and post-TAVI permanent pacemaker insertion. The onset of atrioventricular conduction disturbance that requires PPI remains a common complication of TAVI. Currently, there is much inconsistency in TAVI pathways across the UK and there is no consistency in the PPI protocols following TAVI. Historically, identification and early referral of AS has been the focus: pacing has not always been considered during assessment. 

Permanent pacemaker insertion after TAVI increases hospital mean length of stay and increased readmission rates, which presents capacity issues, especially during the COVID-19 pandemic. Furthermore, the long-term benefits in symptom improvement of TAVI appear to be lessened by PPI. But, these may influence PPI decisions as more often than not care decisions post-TAVI are based on hospital bed capacity. 

It is, therefore, important to clearly define an improved best practice TAVI care pathway with a standardised protocol for PPI embedded within and which avoids patient delays; however, developing a consistent care pathway across different geographical areas remains challenging. Improving the referral pathway for patients could increase capacity in organisations for TAVI procedures and increase organisational efficiency of the MDT. 

Pacing is recognised as an important issue, particularly in changing the risk profile of TAVI patients. Yet there is wide variation in practice across the UK for many aspects of the TAVI pathway, and no standardised pacing protocol.

This is an area which requires further discussion to agree best practice guidelines for clinicians in order to minimise rates of PPI post-TAVI, valve choice should be made by clinicians in an MDT setting and to enable patients to have an informed choice about their treatment plan. There is particular need for more data to understand how PPI impacts patient outcomes over the long term and to help guide both case and device selection, especially among younger patients.

Management of severe symptomatic aortic stenosis in the age of COVID-19: A key paper summary

The management of ssAS patients globally has been turned topsy-turvy in the world of COVID-19. Most hospitals have put elective procedures on hold, despite the fact that non-treatment puts these patients at greater risk of mortality/cardiovascular deterioration (Smith) and that elderly patients with AS are a high-risk group for infection with the virus.

The post-COVID-19 care of these patients face challenges that affect patients, health systems, personnel and providers:

• There are many more patients on the waiting list than there were pre-pandemic
• Hospital resources are impaired, e.g. there are COVID-19 patients who occupy hospital beds, and there is an overload of non-COVID-19 patients who are awaiting treatment. There is a requirement to maximise organisational and economic efficiencies
• Staff may still be recovering, or slow to return from diverted responsibilities
• There may be a lack of clinical specialists or supplies

It will be of the utmost importance that hospitals employ processes and procedures that adhere to clearly defined clinical pathways that maintain patient safety, plan clinical outcomes, maximise resource utilisation, plan for safe, early discharge and provide patient satisfaction.

Those features that make transcatheter aortic valve implantation (TAVI) the treatment of choice for all-risk patients who suffer from severe, symptomatic AS (ssAS) pre-COVID-19 are of even greater significance during the COVID-19 recovery phase.

This key paper summary highlights the evidence base that supports the use of the SAPIEN 3TM platform for the treatment of all-risk patients with ssAS. Snap-shot evaluations of key papers can be found in the Appendix. The advantages of this system over SAVR in terms of the management of ssAS, organisational efficiency, economic impact and patient safety and satisfaction were of compelling impact before the COVID-19 pandemic. This is even more the case as the world emerges from the pandemic.