Post-TAVI readmissions: context and clinical drivers

Patients with aortic stenosis increasingly undergo transcatheter aortic valve implantation, shifting the focus of quality from procedural success to longitudinal outcomes such as hospital readmissions. In many centers, early returns are concentrated within the first 30 to 45 days, a period characterized by medication titration, rhythm surveillance, and recovery from access-site trauma. The population is older, multimorbid, and often frail, so small perturbations in volume status or rhythm can trigger urgent care visits. Within this landscape of structural heart disease, intensified follow-up seeks to close communication gaps and accelerate response times.

Readmissions after TAVI are clinically heterogeneous. Some are cardiopulmonary, including new conduction disturbances, atrial arrhythmias, and volume shifts that can precipitate or unmask heart failure. Others reflect access-site complications, kidney injury, or medication-related adverse effects. A nontrivial portion arises from symptom uncertainty outside regular hours, where a low threshold for emergency evaluation often substitutes for structured guidance and open lines to the care team. The challenge is to balance safety with judicious triage, maintaining vigilance while avoiding default escalation.

In many programs, roles and handoffs across the heart team are not standardized once the patient leaves the cath lab. Nursing, pharmacy, electrophysiology, and primary cardiology input can be asynchronous, leaving patients with fragmented messages. Early post-discharge calls, scripted symptom checks, and clear escalation criteria are pragmatic tools to counter this, but they demand capacity and coordination. Intensified follow-up operationalizes these components, transforming ad hoc outreach into a defined pathway with accountable owners.

Why readmissions persist despite procedural success

Several mechanisms sustain post-TAVI utilization even as intraprocedural risk declines. Conduction disease may evolve over days, not minutes, making late high-grade block or symptomatic bradycardia difficult to anticipate without planned reassessment. Volume management can be delicate, especially in patients with preserved ejection fraction physiology, pulmonary hypertension, or concomitant kidney impairment. For individuals with baseline frailty, small functional setbacks translate into disproportionate care needs and anxiety-driven help-seeking.

Medication optimization is another driver. Transitions from inpatient to outpatient regimens introduce uncertainty around diuretics, antithrombotics, and antihypertensives. Without timely feedback loops, patients can stray from targets or develop side effects that prompt urgent visits. Social determinants, caregiver capacity, and access to transportation influence whether early concerns become readmissions or are managed through ambulatory channels. The common thread is the value of proactive contact and rapid problem classification.

What intensified follow-up attempts to fix

An intensified pathway attempts to replace episodic, patient-initiated contact with scheduled, proactive touches during the highest-risk period. Typical elements include structured symptom inventories, targeted vitals review, medication reconciliation, and streamlined escalation to clinicians who can adjust therapy or bring patients in urgently when appropriate. When combined with remote monitoring for rhythm or weight, these contacts can surface early warning signs and reduce delays to action. Importantly, clear documentation and shared workflows ensure continuity when different team members interact with the same patient over days to weeks.

Communication channels matter. Dedicated phone lines, secure messaging, and 24- to 48-hour response commitments set expectations and foster trust. Scripted pathways help triage common issues like dyspnea, palpitations, dizziness, and access-site concerns, while protecting against over- and under-reaction. In practice, intensified follow-up is a blend of standardized content and patient-specific tailoring, guided by baseline risk, home supports, and comorbidities. The PREMISS program evaluates the feasibility of knitting these elements together in a reproducible way.

PREMISS feasibility: what an intensified pathway looks like

The PREMISS randomized controlled trial, reported as a feasibility evaluation, tested whether a structured, intensified follow-up protocol could be delivered consistently after TAVI and whether acceptability and operational metrics supported scale-up. Details and the abstract are available on PubMed. The central signal is that such a pathway is deliverable and safe, with patterns suggestive of fewer preventable touchpoints with urgent care. These feasibility findings are a prerequisite for larger effectiveness trials that can quantify impacts on readmissions, emergency department visits, and total cost of care.

Feasibility encompasses several dimensions: recruitment and randomization performance, fidelity to the contact schedule, completion of assessments, and the incidence of protocol-related harms. It also includes staff workload and the ability to meet predefined response times. From a patient perspective, acceptability hinges on perceived usefulness, clarity of instructions, and confidence in rapid access to care when needed. PREMISS points toward the practicality of aligning these moving parts into a coherent and replicable follow-up experience.

Encounter cadence, escalation rules, and roles

Intensified programs often use a cadence that concentrates contact in the first 2 to 3 weeks, then tapers as stability is demonstrated. While PREMISS feasibility results do not prescribe a single cadence, they support a model where initial outreach is timely, standardized, and connected to explicit escalation thresholds for in-person evaluation. Nurse-led triage with cardiologist backup is common, and electrophysiology involvement may be triggered by rhythm alerts or symptomatic bradycardia. Pharmacy input is particularly valuable for antithrombotic management and diuretic titration.

Escalation rules should be transparent. Algorithms that map symptom severity, vital sign changes, and device or monitor alerts to specific actions reduce variability and the cognitive load on triage nurses. This approach also facilitates training and maintains consistency across staffing shifts. The heart team benefits from a shared rubric that channels common post-TAVI problems into predictable workstreams with defined accountability.

Patient experience and equity considerations

Older adults value reassurance and clarity about what is normal during recovery. Intensified follow-up provides a venue to reinforce expectations, normalize transient symptoms, and surface issues that merit attention. Incorporating patient-reported outcomes can align contact agendas with what matters most to patients, capturing functional recovery and symptom burden that might otherwise be overlooked. Translation services, caregiver inclusion, and simple educational materials enhance reach and effectiveness across diverse populations.

Equity hinges on access. Not all patients can or wish to use smartphones or web portals, so telephone-first models remain essential. Transportation, home supports, and hearing or vision impairments need proactive accommodation. Programs should minimize technology barriers while retaining the option to layer digital tools for those who prefer them. The PREMISS feasibility signal supports the notion that intensified follow-up can be inclusive when designed with flexibility and patient preferences in mind.

From feasibility to workflows: implications for the heart team

Feasibility alone does not guarantee outcome gains, but it allows programs to build and iterate confidently. The next step is to blend structured content with risk-adaptive intensity, reserving the highest-touch model for those most likely to benefit. This is where risk stratification informs scheduling, monitoring modality, and thresholds for escalation. A learning system approach can refine the pathway over time by linking triage decisions to downstream outcomes and feeding those insights back into protocols.

Intensified follow-up should anchor a broader transitional care strategy that begins before discharge. Patient education, medication reconciliation, and early appointment scheduling set the stage. Clear documentation in the electronic record ensures that on-call clinicians can quickly understand the plan and prior contacts. Cross-cover clarity reduces duplication and prevents delays when multiple team members interact with the same patient.

Integrating risk stratification and remote monitoring

Risk models for post-TAVI events typically incorporate age, renal function, baseline conduction disease, access route, and comorbid cardiopulmonary conditions. Combining these factors with real-time signals from remote vitals or rhythm surveillance can sharpen prioritization. For example, remote pulse or ECG monitoring may be most impactful in patients with new bundle-branch block or transient intraprocedural conduction disturbances. Weight and symptom diaries can be reserved for those with prior congestion or borderline volume status, aligning intensity with need.

Successful integration of monitoring requires clear workflows for alert management. Thresholds should be calibrated to balance sensitivity and specificity, with escalation to clinicians who can act on the information in a timely manner. Feedback to patients about how their data are used sustains engagement and trust. The feasibility of these layers, as suggested by PREMISS, is heartening, but their effectiveness will ultimately be judged by reductions in unplanned care and improvements in patient-centered outcomes.

Measuring what matters: outcomes and value

A comprehensive evaluation of intensified follow-up must span clinical, experiential, and economic endpoints. Beyond 30-day readmissions, programs should track emergency visits, urgent clinic encounters, and time to problem resolution. Patient experience, confidence in self-management, and functional recovery add context to utilization metrics. In parallel, resource use and staffing demands inform sustainability and potential alignment with value-based care incentives.

Data granularity is crucial. Disaggregating readmissions by cause clarifies which components of the pathway drive benefit, whether rhythm surveillance, diuretic titration, or access-site management. Time-stamped logs of contacts and escalations enable process improvement and can reveal bottlenecks. Health systems can leverage these insights to right-size staffing, refine triage scripts, and tailor content to the most frequent drivers of post-TAVI utilization.

Research agenda and practical steps today

Feasibility findings from PREMISS justify larger, pragmatic trials powered for readmissions and cost outcomes, ideally with cluster randomization to reflect real-world workflows. Comparative effectiveness work could test diverse bundles of intensified care, from nurse-led phone programs to digitally augmented models, and explore how risk stratification modifies benefit. Subgroup analyses should address conduction disease, baseline heart failure phenotype, kidney function, and social determinants that shape response to follow-up intensity.

Heart teams do not need to wait for perfect evidence to operationalize low-risk, high-yield elements. A concise, scripted call within 72 hours of discharge, a rapid-access line staffed by clinicians who can adjust therapy, and a clear plan for rhythm surveillance in conduction-risk patients are practical starting points. Embedding these steps within a shared protocol creates consistency and measurability. As programs iterate, linking process metrics to outcomes will close the loop and sustain improvement.

In synthesis, PREMISS contributes a pragmatic and encouraging signal: a structured, intensified follow-up pathway after TAVI is feasible, acceptable, and primed for definitive testing. The path forward centers on risk-adaptive design, patient-centered communication, and disciplined measurement of utilization and recovery. While numerical effect sizes await larger trials, the direction of travel is clear. Translating feasibility into routine practice will depend on thoughtful workflow design and continuous learning within and across heart teams.