1Universitätsklinikum Ulm Klinik für Innere Medizin II Ulm, Deutschland
Introduction:
Streamlining of peri-procedural pathways is a cornerstone in the evolution of interventional cardiology. This reduces the length of hospital stay and thus the healthcare costs and risks for patients. Post-procedure admission to the intensive care unit (ICU) of patients undergoing transcatheter edge-to-edge tricuspid valve repair (T-TEER) has been the standard practice at our center among others. However, during the Covid-19 pandemic, due to the massive decline in high care hospital beds, primary admission to a cardiologic general care unit, the valve unit (VU), was established at our center.
Aim:
We assessed feasibility and safety of post-interventional management on a VU instead of intermediate or intensive care for T-TEER patients.
Methods:
We conducted a retrospective observational study including 270 consecutive patients who underwent T-TEER between March 2017 and June 2023 at Ulm University Hospital, Ulm, Germany. Patients were admitted to the ICU post-procedure up to April 9th 2020 as standard (n = 53). Subsequent patients were scheduled for admission to a dedicated VU (n = 217). Monitoring at the VU included continuous telemetric ECG-recording, oxygen saturation assessment and periodical blood pressure measurements as well as 24-hours physician presence. In contrast to the ICU, only non-invasive blood pressure measurements, less frequent laboratory controls and less intense fluid monitoring took place. We compared the groups and assessed length of hospital stay and in-hospital events, including unplanned transfer to the ICU and predictors thereof.
Results:
The postinterventional hospital stay of patients with planned VU-admission was significantly shorter compared to patients with planned ICU-admission. 37 patients that were planned for the VU had to be transferred to the ICU (cross-over, 17.1 %). Most common reasons for unplanned transfer to the ICU were prolonged need for catecholaminergic drugs (48.6 %) and mechanical ventilation (29.7 %). Patients with unplanned ICU transfer were more often male (67.6 % vs. 40.6 %, p = 0.003) and suffered from diabetes mellitus type II (43.2 % vs. 23.3 %), p = 0.029). Regarding their symptoms before T-TEER, they had worse NYHA functional class (3.11 ± 0.56 vs. 2.88 ± 0.61, p = 0.038), and more frequent right heart failure (64.9 % vs. 45.6 %, p = 0.035), ascites (21.6 % vs. 6.7 %, p = 0.042) and extended peripheral edema (67.6 % vs. 41.7 %, p = 0.004). Their pre-interventional tricuspid regurgitation (TR) grade was more severe (4.19 ± 0.75 vs. 3.87 ± 0.76, p = 0.019). Right atrial (17.19 ± 5.55 vs. 14.20 ± 5.81, p = 0.010) and systolic pulmonary artery pressures (sPAP) (57.36 ± 14.56 vs. 47.80 ± 14.16, p = 0.002) as well as Troponin T values (42 (29.5, 73.5 vs. 34 (20, 57), p = 0.016) were higher.
A higher sPAP (OR 1.049, 95 %-CI 1.016 – 1.083, p = 0.003), NYHA functional class >= III (OR 9.176, 95 % CI 1.139 – 73.937, p = 0.037), and pre-interventional TR grade V (OR 2.941, 95 % CI 1.088 – 7.948, p = 0.033) were found to independently predict unplanned transfer to the ICU.
Conclusion:
Postinterventional admission to the VU instead of the ICU after T-TEER is associated with a shorter postprocedural hospital stay. Unplanned transfer to the ICU affects patients with more advanced right heart failure reflected by higher sPAP, worse NYHA functional class, more often ascites and edema, and high pre-interventional TR grade.