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MyMichigan Health experienced an increase in post-TAVR heart failure admissions in 2019 and 2020.

The team found that potential TAVR patients who needed heart failure referrals were often referred to the heart failure clinic too late. Many times, the patients’ TAVR procedures fell within the week of their heart failure referral which did not allow time to optimize the patients’ medical management before their procedure and safely move forward, resulting in cancellations or admissions for heart failure post procedure.

Providers at MyMichigan Health questioned how they might refer patients to the heart failure clinic early. What should be the parameters for a referral? How could providers work to decrease post-TAVR readmissions?

The structural heart team collaborated with Dr. Jeffrey D. Martindale, director of MyMichigan Health’s Heart Failure Program, to improve care and outcomes for TAVR patients. Dr. Martindale reviewed data from patients admitted to the hospital. He looked at pre- and post-procedure results of proTBNP – a test that measures B-type Natriuretic Peptide in the bloodstream to diagnose heart failure.  He also looked at creatinine – which can indicate a decrease in renal function, common in those with heart failure – and ejection fraction, which measures the amount of blood the heart pumps with each beat. He considered if patients had been previously diagnosed with heart failure. Dr. Martindale then analyzed the data and developed a criterion for referring patients to heart failure for optimization.

Patients with one or more of the following were referred to the heart failure clinic:

1.  History of heart failure
2.  Creatinine > 2.0
3.  ProTBNP > 1000
4.  Ejection Fraction < or equal to 40%

The structural heart team implemented these criteria when screening referrals for TAVR and qualified patients were referred to the heart failure clinic unless they were dialysis patients.

With this protocol implemented, heart failure admissions in the next six months were down to zero. There was appropriate time to optimize patients before their procedures, and patients’ TAVR procedures were not getting canceled the day of.

To show due diligence, the team creates a case presentation slide on all referrals that might be considered a candidate for TAVR. The slide includes the heart failure screening criteria listed above and a note about referral indication or if the patient was already a heart failure clinic patient.

Patients needing mitral valve procedures were even more prone to heart failure. When the team started looking at mitral valves and doing mitral procedures, they adopted this protocol for all valve patients, adding the additional criteria of referrals for patients with moderate to severe pulmonary hypertension.

The key with patients with mitral valve disease is to maximize them on guideline-directed medical therapy when possible. If optimized on heart failure medications, some patients do not require any procedural intervention and their heart failure team can monitor them – a win for the patient.

MyMichigan Health will soon implement a tricuspid program and the team will screen tricuspid patients much like they screen aortic stenosis and mitral patients.

The MISHC TAVR Readmission Prevention Best Practice Protocol includes the protocol developed by MyMichigan Health.

This work is an excellent example of how the lessons we learn from MISHC data-informed quality improvement projects are shared across the consortium to improve quality of care and outcomes in Michigan.