Remote ECG Monitoring of TAVI Patients

Study Overview
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Brief Summary
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After surgery, patients who undergo transcatheter aortic valve implantation (TAVI) are at risk of developing cardiac arrhythmias such as heart blocks and atrial fibrillation. Current practice is to monitor TAVI patients in hospital for 2-8 days post procedure using scarce and expensive hospital telemetry beds. This study will use a new monitoring service called mobile Cardiac Arrhythmia Diagnostics Service (m-CARDS) to risk stratify patient pre-TAVI and provide an added layer of monitoring that would support earlier discharge of suitably identified patients 24-hours post TAVI. The study will assess whether this strategy will significantly reduce the pressure on hospital resources while improving patient outcomes and experience.

Detailed Description
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Aortic stenosis (AS), the most common valvular heart disease, occurs when there is a narrowing of the aortic valve opening. New transcatheter aortic valve implantation (TAVI, also called transcatheter aortic valve replacement [TAVR]), is a minimally invasive surgical procedure that is rapidly expanding as the dominant treatment modality for elderly patients with AS. Approximately 1000 patients will undergo TAVR surgery in Ontario in fiscal year 2018-2019 and that number is expected to increase to  80% of all valve replacement surgery within the next 5 years. Patients that undergo TAVI are at risk of developing cardiac arrhythmias such as heart block and atrial fibrillation and many are routinely monitored in-hospital for 5-8 days post-surgery. Currently, this monitoring is done using scarce and expensive hospital telemetry beds. This study uses a novel clinical pathway including remote monitoring pre- and post-TAVI using a new service called mobile Cardiac Arrhythmia Diagnostics Service (m-CARDS™). m-CARDS™ consists of a patient cardiac monitoring device that transmits cardiac data in real time to a centralized center. Patients wearing the device can remain in the comfort of their own home while being monitored remotely. The monitoring device is Health Canada approved and has been used extensively. Because it is highly sensitive to cardiac arrhythmias, including all levels of heart block, it is ideally suited for this type of monitoring. If this pathway is adopted across all centres it will significantly reduce the pressure on hospital resources while at the same time improve the patient experience, enabling them to get home sooner. Hospital telemetry is very expensive. Reducing the length of stay from 2-8 days on average to 24hr for many patients would represent cost savings to the hospitals and province. While some studies show that patients could be discharged earlier, there is still significant variability in adopting a short length of stay post-TAVI due to a perceived need for inpatient monitoring and lack of adequate knowledge and data on feasibility of remote outpatient monitoring. In addition, the pre-TAVR monitoring will enhance our ability to predict and plan for interventions such as permanent pacemaker implantation. The primary objective of this project will be to facilitate the implementation of this monitoring technology into a busy tertiary care setting and better understand the conditions necessary for successful implementation. This will be achieved through ongoing stakeholder engagement (patient, provider, and hospital administrators) at all stages of the implementation program and close evaluation of quality metrics to ensure fidelity of the m-CARDS™ system. Overall, implementation of this system is expected to impact the following levels of the health care system: i) Patient-Level: Improved quality of life through better care closer to home facilitated by physician supported monitoring before TAVI and post-TAVI discharge from hospital. ii) Provider-Level/Organizational-Level: Integrate the m-CARDS™ system into a busy TAVI clinical care pathway that can be adapted at other TAVI centres and ensure physician/administrator engagement/confidence in this novel technology. iii) System-Level: Reduced (1) hospital length of stay and associated costs, (2) readmissions and unplanned medical visits, and (3) likelihood of hospital acquired infections.

Official Title
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Remote ECG Monitoring to Reduce Complications Following Transcatheter Aortic Valve Implantations

Conditions
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Cardiac Valve Disease, Aortic Valve Stenosis

Intervention / Treatment
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* Device: mobile Cardiac Arrhythmia Diagnostics Service (m-CARDS)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All patients selected for TAVI procedure that do not meet exclusion criteria and provide informed consent. Exclusion Criteria: Patients with prior PPM or ICD Patient in-hospital awaiting TAVI Resting 12-lead ECG shows first degree AV block, plus LAHB plus RBBB; high grade 2nd or 3rd degree heart block
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Intervention Model: Single Group Assignment
Interventional Model Description: Prospective cohort of consecutive patients booked for outpatient TAVI.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Outpatient TAVI<br>Consecutive patients scheduled for outpatient TAVI. | Device: mobile Cardiac Arrhythmia Diagnostics Service (m-CARDS)<br>* A wearable cardiac monitoring device is provided to patients pre- and post-TAVI. The monitor transmits cardiac data in real time to the m-CARDs team. Cardiac abnormalities are reported to the clinical team who then assess the abnormality and intervene as clinically necessary.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Feasibility: Recruitment rate | To achieve recruitment of at least 80% of eligible patients and to describe reasons for non-participation. | End of study (Approximately Month 24) | 
| Feasibility: Participant adherence to monitoring pre-TAVI | To achieve patient level adherence to monitoring at least 80% of the expected time (total # of days (hours) of loop monitoring pre-TAVI). | End of pre-TAVI monitoring period (Day 14) | 
| Feasibility: Participant adherence to monitoring post-TAVI | To achieve patient level adherence to monitoring at least 80% of the expected time (total # of days (hours) of loop monitoring post-TAVI). | End of post-TAVI monitoring period (approximately Month 2 dependent on scheduling of TAVI procedure) | 
| Feasibility: Requirement for PPM pre-TAVI | Pre-TAVI identification of at least 5-10% of the cohort population who would need permanent pacemaker (either heart block or characteristics high risk for heart block). | End of pre-TAVI monitoring period (Day 14) | 
| Feasibility: Participant adherence to post-TAVI monitoring protocol | To facilitate complete success with post-discharge monitoring in > 80% of recruited and eligible participants (wearing monitor on same day as discharge for at least one week). | End of post-TAVI monitoring period (approximately Month 2) | 
| Feasibility: Timeliness of medical assessment of participants with serious arrhythmia identified on monitor pre-TAVI | To have 80% rate of medical assessment within 24 hours for any recruited and eligible patients with identified serious arrhythmia pre-TAVI. | End of pre-TAVI monitoring period (Day 14) | 
| Feasibility: Timeliness of medical assessment of participants with serious arrhythmia identified on monitor post-TAVI | To have 80% rate of medical assessment within 24 hours for any recruited and eligible patients with identified serious arrhythmia post-TAVI. | End of post-TAVI monitoring period (approximately Month 2) | 
| Patient Experience Questionnaire | Survey of patient experience related to shortened length of hospital stay due to remote ECG monitoring via loop monitor and experience of care given when there are clinical findings on loop monitor | 30-day follow-up | 
| Clinical Team Experience Questionnaire | Survey of clinical team experience related to implementation of a new clinical pathway for pre- and post-procedure care of TAVI patients. | 30-day follow-up | 
| Number of participant or clinical team activations based on monitor findings pre-TAVI | Total number of clinical team and participant activations, along with a) Inappropriate clinical team and participant activations - clinical team is activated but no patient intervention is undertaken and b) Inappropriate negative activations - arrhythmia event is seen on loop monitoring but clinical team is not activated. | End of pre-TAVI monitoring period (Day 14) | 
| Number of participant or clinical team activations based on monitor findings post-TAVI | Total number of clinical team and participant activations, along with a) Inappropriate clinical team and participant activations - clinical team is activated but no patient intervention is undertaken and b) Inappropriate negative activations - arrhythmia event is seen on loop monitoring but clinical team is not activated. | End of post-TAVI monitoring period (approximately Month 2) | 
| Time from identification of findings on remote monitor to clinical team activation for pre-TAVI findings. | Time from when a finding is noted on remote monitor to the time the clinical team is activated to assess and intervene with the participant. | End of pre-TAVI monitoring period (Day 14) | 
| Time from identification of findings on remote monitor to clinical team activation for post-TAVI findings. | Time from when a finding is noted on remote monitor to the time the clinical team is activated to assess and intervene with the participant. | End of post-TAVI monitoring period (approximately Month 2) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospital length of stay post-TAVI | Duration of hospitalization post-TAVI procedure. | Month 2 (approximate, dependent on scheduling of TAVI procedure) | 
| Arrhythmia-related unplanned re-hospitalization | Unscheduled hospitalization or prolongation of hospitalization for heart rhythm reasons or PPM insertion pre- or post-TAVI. | 30-day post-TAVI follow-up assessment | 
| New onset of advanced AVB pre-TAVI | Defined as 2:1 second-degree or higher AVB. | End of pre-TAVI monitoring period (Day 14) | 
| New onset of advanced AVB post-TAVI | Defined as 2:1 second-degree or higher AVB. | End of post-TAVI monitoring period (approximately Month 2) | 
| New onset paroxysmal AF pre-TAVI | Defined as any irregular atrial rhythm with absence of consistent P waves lasting > 6 seconds. | End of pre-TAVI monitoring period (Day 14) | 
| New onset paroxysmal AF post-TAVI | Defined as any irregular atrial rhythm with absence of consistent P waves lasting > 6 seconds. | End of post-TAVI monitoring period (approximately Month 2) | 
| New onset atrial tachycardia pre-TAVI | Defined as period of sudden rapid and regular atrial rhythm with identifiable P waves. | End of pre-TAVI monitoring period (Day 14) | 
| New onset atrial tachycardia post-TAVI | Defined as period of sudden rapid and regular atrial rhythm with identifiable P waves. | End of post-TAVI monitoring period (approximately Month 2) | 
| New onset NSVT pre-TAVI | Defined as runs of >/= 3 ventricular beats at a heart rate of > 100 bpm lasting < 30 seconds. | End of pre-TAVI monitoring period (Day 14) | 
| New onset NSVT post-TAVI | Defined as runs of >/= 3 ventricular beats at a heart rate of > 100 bpm lasting < 30 seconds. | End of post-TAVI monitoring period (approximately Month 2) | 
| New sustained VT pre-TAVI | Defined as ventricular runs lasting >/= 30 seconds. | End of pre-TAVI monitoring period (Day 14) | 
| New sustained VT post-TAVI | Defined as ventricular runs lasting >/= 30 seconds. | End of post-TAVI monitoring period (approximately Month 2) | 
| Severe bradycardia pre-TAVI | Defined as heart rate < 40 bpm. | End of pre-TAVI monitoring period (Day 14) | 
| Severe bradycardia post-TAVI | Defined as heart rate < 40 bpm. | End of post-TAVI monitoring period (approximately Month 2) | 
| New onset persistent LBBB | Defined as new onset LBBB after TAVI that persisted at hospital discharge. | Month 2 (approximate, dependent on scheduling of TAVI procedure) | 
| Temporary PM required post-TAVI | Temporary PM not removed within 4 hours of completion of leaving procedure room. | Month 2 (approximate, depending on scheduling of TAVI procedure) | 
| Total number of PPM implantations | Total number of PPM implantations that are either planned (if the inciting heart rhythm was identified on monitor and implantation of PPM was arranged) or unplanned (if the monitor was not the initiating factor). | 30-day post-TAVI follow-up | 
| Total hospitalization days up to 30 days post-TAVI | Number of days in hospital after discharge from TAVI procedure. | 30-day post-TAVI follow-up | 
| Emergency Department (ED) Visits | Number of ED visits. | 30-day post-TAVI follow-up | 
| Health care utilization costs | Costs associated with length of stay, ED use, re-admission to hospital and outpatient clinic visits will be calculated. | 30-day post-TAVI follow-up | 
| Syncope requiring medical assessment | Any incident of syncope that requires medical assessment. | 30-day post-TAVI follow-up | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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TAVR, TAVI, Heart block, Atrial fibrillation, Cardiac arrhythmias, Permanent pacemaker, Remote cardiac monitoring, Loop monitor