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Nursing and Allied Health Professions Investigator Award / Unmet needs and future directions around TAVI
1256 | BEDSIDE
Family involvement in decisions concerning implantable cardioverter
de?brillators: results from an international survey
L.M. Hill 1 , S. McIlfatrick 2 , B. Taylor 3 , P.F. Slater 3 , T. Jaarsma 4 , A. Stromberg 4 ,
D. Fitzsimons 5 . 1 Queen?s University of Belfast and Belfast Health and Social Care
Trust, Belfast, United Kingdom; 2 University of Ulster, Jordanstown, and All Ireland
Institute of Hospice and Palliative Care, Belfast, United Kingdom; 3 University of
Ulster, Jordanstown, United Kingdom; 4 Linkoping University, Linkoping, Sweden
5
Queen?s University of Belfast and All Ireland Institute of Hospice and Palliative
Care, Belfast, United Kingdom
Background: European and International expert guidelines recommend patients?
with an Implantable Cardioverter De?brillator (ICD) and their families are informed
about deactivation. Recent empirical studies demonstrate diverse professional
opinion regarding the involvement of family in the discussion about deactivation
to dying patients.
Purpose: To determine the impact of family involvement on healthcare professionals? decision to discuss ICD deactivation.
Methods: Data from a systematic review, retrospective case note review and
ten case studies identi?ed social support as an important factor or Independent
Variable (IV). The IV was classi?ed into three levels, before being randomly assigned within vignettes of a factorial survey. The anonymised survey consisted of
six vignettes, a demographic questionnaire and an opportunity for participants to
record their most ?recent case?. The survey was distributed electronically through
a secure IT platform to healthcare professionals across Europe and America.
Analysis included descriptive statistics, in addition to Multiple Regression and
ANOVA to identify correlations between social support as an IV and two dependent variables. Thematic analysis was conducted on the qualitative data obtained
from ?recent cases?.
Results: A total of 1614 vignettes were completed by 269 professionals (168
nurses, 64 clinicians, 37 allied health professionals), mean age 46 years (range
26?65 years) with majority from Europe (n=217, 81%). Social support did not impact the likelihood of professionals? to discuss ICD deactivation (p=0.740). However, professionals who managed patients living with a family member who shared
healthcare decisions with them, were signi?cantly more con?dent (p=0.014) in
discussing deactivation, compared to professionals caring for patients with no
family support. Almost half of participants (N=35; 44%) who provided a recent
case documented family involvement. This ranged from a supportive shared role
?wife was terri?ed of seeing her husband shocked on his deathbed, contributing
to a decision? (Healthcare Professional 1) to that of a surrogate decision-maker
?family made the decision to deactivate the ICD as death was clos? (Healthcare
Professional 2).
Conclusions: Family members can play an important role in the decision whether
to deactivate an ICD, however this is contingent on their knowledge and previous
involvement. Professionals should ensure families are involved in discussions and
encourage shared decision-making. Further research is needed into the interventions required to support family members, ultimately improving end-of- life care for
patients with an ICD.
Acknowledgement/Funding: Work Supported by Public Health Agency, HSC
Research and Development division. Awarded HFA Nurse Fellowship grant 2014
male, and the mean logistic EuroScore was 20�%. TAVI procedures were most
commonly performed transfemorally (88%). A total of 207 patients (15.2%) had
residual more-than-mild PVR after TAVI. Compared to patients with no/mild PVR
(n=1158), those with more-than-mild PVR were more commonly male (55.6%
vs. 40.3%, p<0.001), had a higher logistic EuroScore (22�% vs. 20�%,
p=0.02), were more commonly treated through the transfemoral route (92.8%
vs. 87.1%, p=0.02), and more commonly received the self-expanding CoreValve
prosthesis (91.8% vs. 80.4%, p<0.001). In-hospital and 1-year mortality were
signi?cantly higher in patients with more-than-mild PVR as previously reported
(14.5% vs. 6.7%, p<0.001, and 30.8% vs. 19.8%, p<0.001, respectively). The
worse outcome of patients with more-than-mild PVR persisted up to 5 years,
with a 5-year mortality rate of 72.7% compared to 56.5% in patients with no/mild
PVR (p<0.001). After adjustment for various confounders, residual more-thanmild PVR remained independently associated with mortality at 5 years (odds ratio
1.52, 95% con?dence interval 1.24?1.85, p<0.001).
Conclusion: In the early TAVI experience using ?rst generation devices, residual
more-than-mild PVR was common. The negative impact of PVR on in-hospital
and one-year mortality persists up to 5 years, implicating that these patients
should be followed-up closely and offered treatment options if possible.
1281 | BEDSIDE
Delayed pacemaker requirement after transcatheter aortic valve
implantation with Sapien 3 - How long should we monitor?
F. De Torres Alba, G. Kaleschke, J. Vormbrock, M. Feurle, W. Stepper, R. Radke,
S. Orwat, H. Reineke, D. Fischer, H. Deschka, G.-P. Diller, H. Baumgartner.
University Hospital Muenster, Division of Adult Congenital and Valvular Heart
Disease, Department of Cardiovascular Medicine, Muenster, Germany
Introduction: How long pts remain at risk to develop conduction abnormalities
(CAs) requiring pacemaker (PM) implantation after transcatheter aortic valve implantation (TAVI) and should therefore be monitored remains controversial.
Methods: We studied the development CAs in 697 consecutive pts treated with
Sapien 3 between January 2014 and January 2017. After excluding valve-in-valve
procedures (n=15), transapical implantations (n=36) and pts with previously implanted PM (n=75) 574 pts remained for analysis. All patients were monitored for
at least 7 days.
Results: Of 574 pts, 193 (34%) developed new conduction abnormalities and
71 (12%) required a permanent PM after TAVI. CAs requiring PM implantation
occurred intraprocedurally in 31pts (44%) while in the remaining 55% they developed with some delay although frequently within 48h (Figure). However, CAs
requiring PM implantation occurred after 48h in still 21% (15 pts) and in 10%
(7 pts) even after 5 days. We analyzed the presence of previous CAs and the
development of new low grade CAs in pts still free from PM indications at 48h
after TAVI (n=518) in order to identify characteristics that may predict delayed PM
requirement (Table). A pre-existing right bundle branch block was the only characteristic signi?cantly associated with development of high grade CAs after 48h
(26.7% vs 6.2%, p=0.014). Of the pts who developed high grade CAs requiring
PM after 48h, 47% had no CAs prior to TAVI, and 27% had neither pre-existing
CAs nor newly developed low-grade CAs within the ?rst 48h.
Pts free of high grade CAs 48h after TAVR
(N=518)
UNMET NEEDS AND FUTURE DIRECTIONS
AROUND TAVI
1280 | BEDSIDE
Long-term impact of prosthetic valve regurgitation after transcatheter
aortic valve implantation: a 5-year follow-up analysis from the German
TAVI registry
M. Abdel-Wahab 1 , N. Werner 2 , A. Linke 3 , H. Sievert 4 , P. Kahlert 5 ,
R. Hambrecht 6 , G. Nickenig 2 , K.E. Hauptmann 7 , S. Sack 8 , S. Schneider 9 ,
U. Gerckens 10 , G. Richardt 1 , R. Zahn 11 . 1 Heart Center, Segeberger Kliniken,
Bad Segeberg; 2 University Hospital Bonn, Bonn; 3 Heart Center of Leipzig,
Leipzig; 4 CardioVascular Center Frankfurt, Frankfurt am Main; 5 University of
Duisburg-Essen, West German Heart Center, Essen; 6 Hospital Links der Weser,
Bremen; 7 Krankenhaus der Barmherzigen Br黡er, Trier; 8 Municipal Hospital of
Munich, Munich; 9 Stiftung Institut f黵 Herzinfarktforschung, Ludwigshafen; 10 St.
Petrus Hospital, Bonn; 11 Hear Center Ludwigshafen, Ludwigshafen, Germany
Background: Paravalvular prosthetic valve regurgitation (PVR) after transcatheter aortic valve implantation (TAVI) is becoming less frequent, but more
than mild forms have been systematically associated with higher mortality at
short- and intermediate-term follow-up. Little is known about the impact of PVR
on long-term outcome after TAVI.
Purpose: To examine the relationship between more-than-mild PVR after TAVI
and long-term mortality.
Methods: The German TAVI registry includes data on 1444 patients treated between January 2009 and June 2010 at 27 centres in Germany. Long-term followup at a mean duration of 4.5 years was obtained for 1378 patients (95.4%). Of
these, the degree of residual PVR was available in 1365 patients, which constitute the population of the current study. Patients were divided based on PVR into
those with no/mild forms and those with more-than-mild PVR.
Results: The mean age of the study population was 81.8�1 years, 42.6% were
Age (yrs)
Gender (n of men, %)
No previous CAs (n, %)
? Previous AVB1 (n, %)
? Previous RSB (n, %)
? Previous LSB (n, %)
New postprocedural low grade CAs (n, %)
No previous and no new postprocedural
CAs within 48h (n, %)
p
No development
of high grade CAs
(N=503)
Development
of high grade CAs
(N=15)
81�288 (57.2%)
327 (65%)
90 (17.9%)
31 (6.2%)
81 (16.1%)
128 (25.4%)
83�7 (46.7%)0.436
7 (46.7%)
3 (20%)
4 (26.7%)
3 (20%)
3 (20%)
0.385
0.436
0.144
0.741
0.014
0.721
0.771
236 (46.9%)
4 (26.7%)
0.188
Conclusion: In this study, in pts requiring PM implantation after TAVI, the high
grade CAs occurred after 48h in 21% and even after 5 days in 10% of pts. More
importantly, 27% of pts eventually requiring a PM had still no CAs at 48h. These
results question the safety of early discharge and support monitoring for approximately 7 days.
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