Page 16 - Read Online

van Wiechen et al. Mini-invasive Surg 2022;6:1 https://dx.doi.org/10.20517/2574-1225.2021.96 Page 9 of 11

Figure 2. Pacing over a left ventricular guidewire.

streamlined TAVI protocol. As such, the vast majority of patients did not go to the (I)CCU (n = 115, 28%)
or were only observed for a period shorter than 24 h (n = 249, 50%). In addition, the number of patients
who underwent TAVI through surgical cutdown of the femoral or subclavian artery was low (3% in total,
results not shown). To further reduce respiratory and wound infections, patients should be actively
mobilized and (I)CCU stay should become an exception instead of standard practice.

Of note, conduction disorders were the most frequent cause of readmission in the R-EXPRES cohort, which
in our experience always required a permanent pacemaker. Ambulatory event monitoring after TAVI could
further optimize discharge policy and detect conduction disorders before they cause harm. A recent pilot
study showed an 8% incidence of delayed high-grade AV-block (≥ 2 days post-TAVI) with a median time to
[23]
AV-block of six days (range 3-24 days) .

Referring hospital involvement
Latest ESC guidelines on valvular heart disease recommend centralized TAVI care in heart valve expert
centers . This recommendation specifically aims to centralize heart valve interventions including TAVI in
[2]
order to maximize local experience and offer optimal procedure outcome. TAVI guidelines require heart
valve centers to have specific institutional resources such as on-site cardiac surgeons and the capability of
running cardiopulmonary bypass, which precludes the TAVI operator from performing the procedure at
the referring hospital without these logistics in place. Therefore, we believe referring hospitals need to be
involved in the work up before and care after TAVI to reinforce the concept and viability of expert heart
valve centers and bring overall TAVI care closer to the patient’s home environment.

Inter-hospital collaborations face specific challenges. In our study, LOS was one day longer for R-EXPRES
patients compared to patients who were not transferred after TAVI [LOS: 5 (4-7) vs. 4 (3-6); P < 0.01]. This
could suggest a knowledge and expertise gap between referring and TAVI expert centers and a lack of a
harmonized protocol. Digital information transfer, shared electronic health records, and continued training
and information exchange could further optimize this inter-hospital collaboration.

Limitations
Selection bias is an intrinsic limitation of every single-center retrospective analysis. The EXPRES cohort had
a larger proportion of the Sapien and Acurate valve platforms: whether short LOS and equal re-
hospitalization rate are attributed to patient selection rather than device selection is unsettled. In addition,
this trial was performed before introduction of the cusp overlay technique, which could have influenced the