Improving care pathways: Permanent Pacemaker Insertion after TAVI
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.
TAVI pathways need to be mapped out with PPI built into the patient journey with a consistent approach that optimises patient outcomes and service efficiency.