Résumé
Indication and duration of telemetry monitoring (TM) after transcatheter aortic valve replacement (TAVR) are not well defined. We hypothesize that a rationalized strategy for screening and monitoring conductive disorders (CD) after TAVR could reduce both the indications and the length of ECG monitoring, without compromising patient safety. Method: we prospectively evaluated consecutive patients undergoing transfemoral TAVR between February 2023 and September 2024. Patients were transferred to intensive care unit (ICU) for TM after the procedure if they had baseline right bundle branch block (RBBB), new or worsening of any preexisting CD, permanent atrial fibrillation with ventricular rate < 40 bpm, based on the ECG performed 1h after the procedure. The length of TM was protocolized: 24h for new or worsening > 20 ms left bundle block branch (LBBB), 48h for LBBB associated with first-degree atrioventricular block (1-AVB) or large LBBB > 150 ms. Preprocedural RBBB required TM during 24h. Patients without any new CD or with stable previous LBBB or 1-AVB were transferred directly to GCW without TM, unless there was a non-rhythmic indication for ICU monitoring. The primary endpoint was the occurrence of serious CD (syncope or sudden death) or CD requiring specific management (drug treatment, extension of hospitalization, need for a transient or permanent pacemaker) outside the ICU at one-month follow-up. Results: the study included 250 patients with a mean age of 80.5 (± 6.8) years, 52.4% were male and the mean EuroSCORE II was 3.2 (± 3.7). According to our selecting criteria, 139 patients (55.6%) were transferred to the ICU for TM, mainly due to new LBBB (60.4%). Primary endpoint occurred in 3 patients who followed the protocol, representing 1.2% of the population, IC [0.312 ; 3.772]: two patients with stable CD at discharge (First had 1-AVB with left anterior hemiblock (LAH) and second had LBBB) experienced non-traumatic syncope respectively on day 6 and day 7 after TAVR related to complete heart block (CHB). One patient with no CD at discharge had new LBBB and 1-AVB on day 8 with dizziness, promoting elective pacemaker implantation. There was 1 death related to a stroke in ICU. There were no serious CD outside the ICU during the hospital stay. Negative predictive value (NPV) of our strategy regarding occurrence of syncope outside the ICU was 99%. The mean pacemaker implantation rate was 16.8% at one month. The mean ICU stay was 1.3 days (± 0.7). The mean global hospitalization length was shorter without ICU admission: 1.4 days (± 1.1) vs 2.9 days (± 2.6) (p<0.001). Conclusion: an in hospital selective strategy of indication and length of TM after TAVR is safe with no in-hospital rhythmic events, 3 non-traumatic CD after discharge and no cardiovascular deaths. This strategy allows to dispense of ICU for ECG monitoring in nearly half of the patients after TAVR and results in very short global hospitalization and ICU lengths of stay, with potentially important economic impact. Prediction of late CD remains a major issue after TAVR.