Why intensified follow-up matters after TAVI

Patients with severe aortic stenosis increasingly receive transcatheter aortic valve implantation, and most are discharged early. That speed challenges teams to compress education, titration, and surveillance into a narrow window. The days and weeks after discharge are where small problems become big ones, and where a structured plan can capture signals before they escalate. A practical pathway aligns scheduled contacts, remote vital signs, medication reconciliation, and clear thresholds for escalation. When these elements are integrated and reliable, preventable readmissions can be minimized without adding undue burden to patients or clinicians.

Baseline risk and typical drivers of rehospitalization

Post-TAVI rehospitalizations cluster around a few clinical themes that are predictable and, in many cases, modifiable. Common drivers include volume shifts causing or worsening heart failure, atrioventricular block or atrial arrhythmias, vascular access site complications, and infections. Several of these problems manifest through recognizable signals: rising weights, new dyspnea, orthopnea, lower extremity edema, presyncope, fevers, or access site swelling and pain. Many also tie back to system-level gaps such as delayed medication reconciliation or unclear instructions about diuretics or anticoagulation. A pathway that anticipates these drivers and makes the first two weeks post-discharge highly structured can change the trajectory.

What PREMISS contributes and what feasibility means

Feasibility work clarifies whether a complex, team-based follow-up model can be delivered as intended, with acceptable adherence and fidelity. In PREMISS, an intensified pathway after TAVI was implemented and evaluated for operational performance, offering a template for scheduling, staffing, and escalation that other programs can adapt. The feasibility results help identify which components are easiest to deliver consistently, where drop-offs occur, and how patients experience the sequence of contacts. While outcomes such as readmissions and emergency visits are crucial, they must be built on a platform that functions reliably day to day. These feasibility data support moving toward larger, outcomes-powered evaluations while already informing practice design.

Patient-centered goals and measurable outcomes

Patient-centered aims should drive the pathway and the metrics that define success. Goals include fewer avoidable rehospitalizations, faster recovery, better symptom control, and high satisfaction with communication and instructions. Measurable process outcomes span on-time contact completion, successful transmission of remote data, medication reconciliation completion, and documented escalation when red flags are met. Patient-reported metrics such as confidence in self-management and clarity about diuretic and anticoagulation plans are equally important. Over time, the program should track not only readmissions but also days alive and out of hospital, urgent visits, and functional status gains.

Designing an intensified post-TAVI pathway

Structured early contacts and escalation logic

Time is the critical variable in the early post-discharge phase, so predictably scheduled contacts anchor the model. A best-practice sequence is a same- or next-day phone call, a 72-hour nurse check-in, a one-week clinic or telehealth visit, and a two-week reassessment that includes medication review and access site inspection. Each interaction should follow a standardized script with embedded red flags and a documented escalation pathway to an advanced practice provider or interventionalist when needed. The PREMISS framework reinforces this choreography to ensure nothing slips through cracks of busy clinics and fragmented calendars. Clear ownership of each contact prevents diffusion of responsibility.

Remote monitoring and actionable thresholds

Remote signals are useful only when tied to actionable thresholds and a response plan. Practical home measures include daily weight, blood pressure, heart rate, pulse oximetry when indicated, and a brief symptom checklist. A simple rule set can guide responses, for example sustained weight gain beyond a defined threshold or symptomatic hypotension prompting same-day review. Where feasible, add telemonitoring with automated alerts routed to a team inbox with daytime coverage. The point is consistency and speed rather than maximal data density, because timely pattern recognition often prevents deterioration.

Medication reconciliation and titration

The most common medication problems after TAVI are omissions, duplications, and unclear instruction about diuretic titration. A tightly run medication reconciliation at or before discharge, with a follow-up verification during the first week, can avert many errors. Written action plans for diuretics and analgesics should be explicit about thresholds, doses, and who to call for advice. Antithrombotic therapy requires special attention given bleeding risk and comorbid atrial arrhythmias. The early nurse or pharmacist contact should verify fills, affordability, and understanding, and document any barriers to adherence.

Rhythm and conduction surveillance

Conduction disturbances are a distinct domain after TAVI, and explicit surveillance is needed to detect late block or symptomatic bradycardia. Patients discharged without a pacemaker but with conduction changes may benefit from a wearable monitor for the first weeks, with clear triggers for urgent review if pauses or high-grade block are detected. For those with preexisting or new atrial fibrillation, early rhythm assessment and anticoagulation checks should be aligned to the first clinic follow-up. Defining escalation pathways for syncope, presyncope, or palpitations shortens time to decision. A consistent handoff to electrophysiology services ensures timely permanent pacing when indicated.

Heart failure and volume management

Even after relief of outflow obstruction, patients may have residual or new volume sensitivity due to ventricular remodeling, diastolic dysfunction, or comorbid kidney disease. Early weight trends and symptoms are the simplest tools to guide diuretic adjustments, supported by review of home blood pressure and heart rate. For patients with significant comorbidity, adding a short course of daily contact or text-based check-ins during the first week can maintain momentum. Where available, natriuretic peptide checks may help interpret ambiguous symptoms. Linking HF-nurse services to the structural team keeps the message consistent and avoids mixed instructions.

Implementing at scale and measuring value

Workflow, staffing, and interoperability

Implementation hinges on defining who does what, when, using which tools, and how information flows back to the team. A practical model assigns a nurse coordinator to run the contact cadence, with advanced practice providers as escalation points and a physician available for decisions. Templates in the electronic record can pre-populate scripts, red flags, and disposition options, reducing cognitive load during busy clinics. Shared inboxes and registries help ensure continuity when staff rotate. Interoperability with home devices is helpful but not mandatory if a consistent self-report mechanism exists.

Equity, access, and caregiver engagement

Any intensified model must be accessible to patients with varying health literacy, language, and technology comfort. Pairing phone-first outreach with optional app-based tools widens reach while keeping core services equitable. Caregivers should be present for key instructions, especially those tied to diuretic adjustments and wound care. Translation services and teach-back techniques improve comprehension and adherence. The pathway should flag social risk factors and connect patients to resources that support transportation, medication affordability, and home health when indicated.

Safety netting, red flags, and after-hours coverage

Clear safety-netting instructions can be as protective as the scheduled touchpoints themselves. Discharge materials and follow-up calls should reiterate red flags such as chest pain, new neurologic symptoms, fever, uncontrolled bleeding, syncope, and rapidly enlarging access site swelling. Patients need to know how to reach the team after hours, and when to bypass routine channels for urgent care. Simple tools, like a wallet card with direct lines and anticoagulation details, reduce friction in emergencies. Aligning messages across inpatient, outpatient, and call-center teams prevents mixed guidance.

Evaluation framework and quality metrics

Programs should begin measuring performance from day one, focusing on process reliability and patient-centered outcomes. Core metrics include on-time completion of each scheduled contact, the percentage of patients who transmit at least one set of home measures in week one, and completion of medication reconciliation within seven days. Outcome metrics should follow, including unplanned visits, readmissions, and days alive and out of hospital at 30 and 90 days. Patient-reported measures of understanding and confidence, captured with brief surveys, can be tied to specific teaching elements to guide improvement. Routine case reviews for every readmission can surface where the pathway missed an opportunity.

Economic considerations and payer alignment

Preventing avoidable rehospitalizations and urgent visits has clear patient value and likely cost benefit, but the payment model determines how the program is resourced. Bundled payments and value-based contracts align incentives to fund coordinators, remote monitoring kits, and dedicated follow-up slots. Even in fee-for-service settings, targeted use of remote assessments and nurse-driven visits can be cost-neutral when they prevent expensive acute care. Payer engagement is easier when the pathway includes explicit metrics and a plan to share outcomes. Institutions should define an implementation budget and track return on investment over time.

Research gaps and next steps

Feasibility provides the operational backbone for rigorous outcomes testing, which should include stratification by baseline risk and comorbidities. Key questions include which components drive benefit and for whom, the optimal intensity and duration of monitoring, and how to tailor escalation to specific complications. Comparative effectiveness studies can test richer remote data versus simpler phone-first models. The PREMISS feasibility report (PubMed) supports proceeding to adequately powered trials focused on readmissions, emergency visits, and patient-reported recovery. Ongoing iteration should be expected as technology, staffing, and patient needs evolve.

In sum, an intensified post-TAVI follow-up model is feasible and aligns with clinician and patient priorities when built on consistent contacts, actionable remote data, and rapid escalation. The PREMISS feasibility experience offers a practical blueprint that programs can adapt now while preparing for outcomes-focused trials. Success will depend on reliable workflows, clear ownership, and thoughtful integration with existing heart teams and community care. With these elements in place, the next phase is to demonstrate durable reductions in preventable readmissions and to refine the model for broad, equitable adoption.