P207 - CLINICAL AND LOGISTICAL IMPACTS OF IMPLEMENTATION OF A STANDARDIZED DECISIONAL ALGORITHM FOR THE MANAGEMENT OF PERI-TAVI CONDUCTION DISTURBANCES

Background: Conduction disturbances following TAVI are frequently encountered and their occurrence has only modestly decreased over time. Heart blocks occur in up to 35% of TAVI procedures and these conduction disorders may lead to permanent pacemaker (PPM) implantation. Management guidance is provided within general guidelines, but numerous gray zones regarding indications and timing for PPM remain, leading to significant variability in management between and even within centers. In this analysis, we explore the impacts of implementing a decisional algorithm designed to promote a more homogeneous approach to peri-TAVI conduction disturbances.

METHODS AND RESULTS: The algorithm was designed and introduced at the Centre Hospitalier de l’Université de Montréal in January 2021. In this retrospective analysis, our entire TAVI cohort from April 2019 to April 2022 (n=334 patients) was screened to identify patients meeting the target population criteria (figure 1) and create pre and post-implementation comparison groups. Patients without conduction disturbances or those with preexisting pacemakers were excluded. The primary endpoint was the incidence of unplanned pacemaker implantation, defined as urgent pacing indication occurring after removal of the procedural temporary wire (during index hospitalization or post-discharge). Secondary endpoints included duration of temporary pacing and length of hospital stay.

A total of 134 patients were included (67 pre and 67 post-implementation). Baseline characteristics were similar between groups. The majority of patients met the criteria of new-onset LBBB (63%, n=84) while 22% (n=29) had a high-degree AV block. Thirty-seven patients required PPM implantation: 18 planned and 19 unplanned. The rate of unplanned PPM was not statistically different after (16%) vs before (12%) protocol implementation (p=0.48). The mean duration of temporary pacing was numerically shorter in the post-implementation group: 11.1h vs 16h pre (p=0.34), but the median length of stay was similar (2.2 days post vs 2.1 days pre; p=0.60). Non-adherence to the algorithm occurred in 49% of patients, mainly due to removal of the temporary pacemaker sooner than protocol-suggested (n= 23, 70%).

Conclusion: In this study, implementation of a standardized algorithm to guide management of conduction disturbances following TAVI did not reduce the rate of unplanned PPM implantations. However, it did not prolong the duration of temporary pacing nor hospital length of stay. Therefore, such protocols can still be of value to guide management and homogenize practice amongst caregivers. In the era of early discharge post-TAVI, further studies are required to best identify predictors of high-degree conduction disturbances to increase performance of management protocols.