Why readmissions persist after TAVI

Severe aortic stenosis increasingly undergoes transcatheter aortic valve implantation as first-line therapy in older and comorbid populations. Yet early hospital readmissions remain common, typically driven by syndromes such as heart failure exacerbation, conduction disturbances, bleeding, and infections. Beyond clinical factors, social and functional determinants influence medication adherence, daily weight tracking, and timely escalation of care when symptoms worsen. These complexities suggest that a one-size-fits-all discharge plan may miss high-risk periods in the first weeks at home. Intensified follow-up after discharge aims to bridge the gap between an uneventful procedure and stable recovery.

Clinical and procedural drivers

Post-procedural hemodynamic changes, conduction system perturbations, and vascular access issues can evolve over days, not just hours. Even when the index hospitalization is uncomplicated, subclinical fluid shifts or slow conduction changes may present as dyspnea, edema, or bradyarrhythmia after discharge. The interface with long-standing comorbidities can amplify risk: renal function fluctuations may alter diuretic effectiveness, while pre-existing atrial arrhythmias can destabilize rate control. Intensified follow-up pathways focus on symptom recognition, prompt medication titration, and reinforcement of warning signs. When executed well, early contact can avert escalation to emergency care by enabling timely outpatient adjustments.

Transitions of care and monitoring gaps

Discharge instructions and scheduled clinic visits do not always capture day-to-day changes in the first weeks at home. Traditional models rely on patients to self-monitor and call when symptoms worsen, which can be difficult for those with limited health literacy or social support. Early phone or video outreach provides an opportunity to assess symptoms, weight trends, and medication adherence. Simple, protocolized questions can detect clinically meaningful changes before they become urgent. Integration of remote monitoring and telemedicine can extend reach without imposing travel burdens on older adults, while nurse-led care provides continuity and pragmatic escalation pathways.

Design and feasibility signals from PREMISS

The PREMISS randomized trial evaluates whether an intensified follow-up protocol after TAVI is practical to implement and capable of reducing unplanned readmissions. As a feasibility readout, key domains include recruitment and retention, protocol adherence, early safety, and acceptability to patients and staff. The intervention appears focused on structured contacts shortly after discharge, symptom review, and standardized triggers for escalation to additional assessment. Although not powered for efficacy, feasibility trials can show directional effects and reveal operational bottlenecks that must be addressed before a larger outcomes trial. The PubMed record provides the canonical entry for these findings: https://pubmed.ncbi.nlm.nih.gov/40957461/.

Population and intervention

PREMISS targets adults undergoing contemporary TAVI, a group characterized by multimorbidity, variable conduction risk, and diverse recovery trajectories. An intensified pathway typically includes one or more early contacts to review symptoms, weights, vitals when available, and medication plans. Beyond routine follow-up, the protocol often standardizes timing and content of outreach, aiming for consistent, reproducible care transitions. Elements can include brief education reinforcement and guided navigation for urgent concerns. Embedding risk stratification helps prioritize those with the highest early risk, such as patients with conduction delays, borderline renal function, or complex social environments. These features are designed to be scalable and to fit within existing post-discharge workflows.

Implementation metrics and fidelity

Feasibility outcomes hinge on whether sites can recruit eligible patients, complete planned outreach within prespecified time windows, and escalate consistently when predefined triggers are met. Fidelity measures may include the proportion of scheduled contacts completed, the completeness of symptom assessments, and adherence to escalation rules. Acceptability is judged by patient and staff feedback on timeliness, clarity, and perceived burden. Trials in this space often report high satisfaction when outreach is personalized, concise, and problem-focused. PREMISS suggests that a structured protocol can be delivered in real-world settings without overtaxing clinic capacity, an important consideration for scale-up.

Clinical signals and safety

While not designed to test effectiveness, feasibility readouts can reveal whether an intervention moves outcomes in the desired direction. PREMISS indicates a plausible reduction in early unplanned readmissions associated with intensified follow-up, with no emergent safety concerns attributable to the protocol itself. These directional findings reinforce the importance of early symptom surveillance and rapid management adjustments. When escalation pathways function smoothly, issues such as fluid overload, wound concerns, or arrhythmia symptoms can be addressed before they require emergency evaluation. Such signals justify the progression to a definitive, adequately powered outcomes trial.

Patient experience and workflow

Older patients often value proactive outreach that confirms recovery milestones and clarifies medication plans. Short, structured calls or telehealth visits minimize travel while maintaining clinical oversight. From a workflow perspective, centralizing outreach through a small, dedicated team supports consistency and reduces duplication across clinics. Shared documentation templates help ensure that findings and actions are visible to the broader care team. These features build a bridge between hospital discharge and the first in-person follow-up, strengthening post-acute care without creating undue burden.

Implications for practice and research

Feasibility outcomes frame the path to implementation and trial expansion. Health systems considering an intensified pathway can plan for staffing, scripting, and telemetry options, and they can set realistic timelines for first contact and follow-up cadence. Patient selection is central: individuals with conduction system disease, renal vulnerability, or limited support at home may warrant closer surveillance. Prioritization aligns resources with risk during the short, high-hazard window after discharge. By linking contacts to standardized escalation triggers, clinicians can convert signal detection into timely intervention.

Operationalising intensified follow-up

Pragmatic implementation uses clear eligibility criteria, a short series of scheduled contacts, and concise scripts that screen for red flags. Integrating symptom checklists, daily weights when feasible, and medication reconciliation improves signal detection. Clear escalation thresholds for in-person assessment or remote device checks streamline decision-making. Embedding the pathway within existing staff roles and EMR workflows supports sustainability. Initial pilots can focus on weekdays with on-call pathways for off-hours issues, then scale up based on observed demand. Aligning the model with institutional quality metrics provides long-term support for resources.

Which patients may benefit most

Risk-enriched strategies can focus intensified follow-up on those most likely to decompensate early. Baseline markers such as reduced ejection fraction, right ventricular dysfunction, or significant diastolic abnormalities increase the chance of fluid-related symptoms after discharge. Procedural features, including new conduction delay or deep valve implantation, may forecast pacemaker requirement or bradyarrhythmia symptoms. Social context matters as well: limited caregiver support, transportation challenges, or language barriers can hinder self-management. Incorporating frailty and cognition screening refines prioritization. Dynamic reassessment after the first contact identifies those who stabilize quickly and those who require continued close attention.

Endpoints and measurement for a definitive trial

A subsequent outcomes trial should prespecify a readmission endpoint by time window and cause, with blinded adjudication where feasible. Secondary endpoints may include emergency department visits, urgent clinic evaluations, and procedure-related complications captured after discharge. Patient-centered outcomes, such as patient-reported outcomes focused on symptoms and recovery confidence, add important context. Economic endpoints should capture costs of outreach, travel avoided, and downstream utilization. When available, device-derived physiological signals can augment clinical assessments, but they should be used judiciously with clear escalation rules. A registry-embedded design could accelerate enrollment and enhance generalizability.

Health system and payer perspectives

From a system standpoint, preventing avoidable readmissions preserves capacity and reduces costs while improving patient experience. Payers may support structured outreach when it is tied to measurable reductions in acute utilization and aligns with value-based contracts. Simple packages that leverage phone-based contact and brief telehealth visits can be cost-effective starting points. As digital tools mature, selective addition of home monitoring can be evaluated against incremental complexity. Coordination with community resources and primary care can extend reach. Careful tracking of avoided acute visits and timely escalations supports business cases for sustained investment.

Limitations and generalisability

As a feasibility trial, PREMISS is not powered to estimate definitive treatment effects on readmissions or mortality. Operational success in one or a few centers may not translate directly to other settings with different staffing, patient demographics, or baseline post-discharge practices. The intensity and timing of contacts must balance benefit with burden; too many touchpoints can reduce engagement. Adherence to scripts and escalation pathways may drift without periodic reinforcement. These considerations argue for thoughtful real-world piloting even as a larger outcomes trial is planned.

On balance, PREMISS offers a clear message: a structured, early outreach pathway after TAVI appears implementable and acceptable, with a favorable directional signal on unplanned readmissions and no new safety concerns. These results support a move toward scalable protocols that prioritize high-risk patients and standardize symptom surveillance and escalation. A definitive trial with prespecified endpoints, robust adjudication, and economic evaluation is the logical next step. Meanwhile, health systems can begin aligning workflows, staffing, and scripts to operationalize intensified follow-up in a measured, data-driven manner. Strengthening care transitions in this vulnerable window has potential to improve outcomes, satisfaction, and resource stewardship.