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Page 8 of 11 van Wiechen et al. Mini-invasive Surg 2022;6:1 https://dx.doi.org/10.20517/2574-1225.2021.96

in addition to different reimbursement policies between countries, it is uncertain if such a progressive
discharge policy in elderly will be accepted worldwide or is applicable for the majority of elderly, more
dependent patients. Involving referring hospitals could alleviate TAVI expert centers by reducing prolonged
[10]
in-hospital stay and bringing care closer to the patient’s home environment. Barbanti et al. touched upon
this option in FAST-TAVI. They showed feasibility of early discharge when adhering to a set of clinical
discharge criteria; median LOS was two days (IQR: 1-4 days), and patients were either discharged home
(79%) or to a referring hospital (16.2%). Our single-center cohort corroborates this concept of early transfer
to a referring hospital as a specific discharge pathway.

Procedure simplification
Over the last couple of years, efforts to streamline the TAVI cascade have focused on various facets within
the expert TAVI center including local anesthesia protocols, simplified TAVI execution, and reducing
invasive instrumentation to a minimum. As such, in our cohort, 96% of the patients were treated under
local anesthesia. Globally, there is a clear shift to perform transfemoral TAVI under local
[15]
anesthesia/conscious sedation rather than general anesthesia . Local anesthesia is associated with shorter
in-hospital and ICCU stays. Taking into account the heterogeneity of the patient population and selection
bias, TAVI under local anesthesia shortens LOS by approximately 1.5 days when compared to general
[16]
anesthesia . Moreover, procedural time and procedural turnover time can be substantially decreased.
Shorter procedure time also precludes urinary catheter insertion, which minimizes the risk for urinary tract
[17]
infections and bleeding . In our experience, median procedural time was approximately 1 h [66 min (51-
84)], and there were no differences between the cohorts (P = 0.14).

Another important adjustment in our simplified TAVI protocol is to pace on the left ventricular guidewire
with alligator clamps and no longer insert a temporary pacemaker through a deep venous access [Figure 2].
Only when a high-degree atrioventricular block occurs during the procedure, venous access for a temporary
[16]
pacing wire in the right ventricular apex is obtained .

Cerebral debris embolization is omnipresent in TAVI, and up to 90% of patients will develop brain injury,
as demonstrated by post-TAVI brain magnetic resonance imaging. Use of filter-based cerebral embolic
protection may cut new brain lesions after TAVI in half . We use embolic protection in all our patients
[18]
when feasible. In this cohort, embolic protection was used in 45% of the cases. Reasons for not using an
embolic protection device were: no calcium in the aortic annulus (e.g., in pure aortic regurgitation),
transaxillary access, or unsuitable anatomy of the filter-landing zone.

In this contemporary cohort, access site related complications remained relevant (37 patients, 9%). The
routine implementation of ultrasound guided femoral access may reduce access site complications; it
precludes radiation and allows for real time visual monitoring of the vessel puncture. Notably, angiographic
confirmation of successful closure device deployment after TAVI may further avoid covert retroperitoneal
bleedings or flow limiting dissections and occlusions.

Re-hospitalization
In total, 34 patients (8%) were re-hospitalized. Heart failure (18%), conduction abnormalities (18%), and
infections (38%) were the most common reasons. Our results are in line with previous reports on
readmissions after TAVI, which have shown that, in more than half of the cases, the reason for readmission
was non-cardiac [19,20] . Infections remain an important issue after discharge, also in our study. Surgical
cutdown of the femoral artery, overweight (BMI ≥ 25 kg/m²), bleeding complications, and ICCU stay have
been identified as predictors for developing infections after TAVI [21,22] . Modifiable factors such as avoiding
surgical cutdown, in-dwelling (urinary) catheters, and shortening ICCU stay have been adjusted in our