Physician perspective

Dr. Gray discusses monitoring during TAVR recovery

William Todd Gray, MD, talks about the crucial role that MCT (mobile cardiac telemetry) can play in a patient’s recovery after TAVR.

Preventice is now Boston Scientific Cardiac Diagnostics

Dr. William Todd Gray. William Todd Gray, MD

BodyGuardian™ helps patients recover safely

When patients are discharged from the Baylor Scott & White TAVR (transcatheter aortic valve replacement) program, they are monitored for 30 days with the BodyGuardian MINI PLUS for MCT (mobile cardiac telemetry). Patients can use the monitor to let their doctors know when they have symptoms; physicians at the Texas health system automatically receive a daily summary per patient.

Boston Scientific Cardiac Diagnostics: How do you use remote cardiac monitoring? Is there a typical patient population you use it with, or is it a tool that’s appropriate for most patients?

Dr. Gray: It depends on the patient subset. With low-risk populations, I'll use shorter-term monitoring. In a young person with a reported near-syncopal event or random occurrence, I would use a Holter monitor for 14 days to obtain data and yields. I'm not worried about unforeseen events if it's low risk and there's no structural abnormalities with the heart and the patient doesn't have a high-risk family history for sudden death. I'll use a longer-term monitoring solution for patients that I suspect may have AFib, flutter, or some tachycardia as the etiology for their symptoms.

Currently with our new structural heart program and TAVR programs, we've been using BodyGuardian monitors.  We use the MINI PLUS for 30 days at discharge on every patient. We do this because incidence of arrhythmias in just the aortic stenosis population is high anyway. When you manipulate any technology in the aortic annulus and left ventricular outflow tract, the risk of damage or irritation of the conduction system increases.

With telemetry we've seen real-time events when we deploy the monitor or shortly thereafter. Also, we've seen lots of later-term arrhythmias that result in other comorbid medical conditions such as high-grade heart block or sustained VT (ventricular tachycardia). The patient can die if you don't catch it. That's where we're focusing our evaluation right now using this technology.

What have you found most helpful for your practice in the latest MCT technology?

Dr. Gray: It's much easier for the patients to complete the course of therapy without worrying about the burdensome, bulky leads that used to be a hindrance. Now it's a patch monitor, and the patients have a smartphone. They can use the phone to let us know when they're having symptoms; this enables us to correlate symptoms with underlying arrhythmias. Our staff will call the patient, discuss, and see whether triggered events were real. Patients can notify us promptly if there's something going on.

What are the key capabilities of MCT with BodyGuardian MINI PLUS?

The key features are the daily summary of MCT data, and that my team can be notified if something's happening throughout clinic. My team would immediately be notified if one of my patients has an arrhythmia and they’d put it right on my desk. Or they can call me out of a room and let me know within minutes that a patient is having a serious arrhythmia and needs to come in.

How does remote cardiac monitoring help you in your management of TAVR patients?

Arrhythmia is very common in this patient population. If you think about reasons for a bad 30-day or one-year outcome and deaths from unknown causes, undetected arrhythmia is high on the list. Having several episodes of complete heart block and heart rates in the teens to 20s with overt syncopal events in patients two or three weeks out after a valve replacement really perked my ears. Maybe those were the kind of patients that died unnecessarily because they were miles away from a hospital, had an event, and nobody was there to see it. We've had two cases like that just since we started the valve program.

Dr. Gray: Knowing that, I chose to incorporate remote cardiac monitoring in the program from the beginning. So, for all patients who don’t already have a device, we'll discharge them from the hospital with a monitor for 30 days. We review that data together and schedule a 30-day follow-up with review of the EKG. After seeing the patient's post operation heart activity, we decide if there are other things that we need to follow more closely.

What is the impact of having MCT on TAVR clinical outcomes?

Dr. Gray: If you're not looking for it with the high incidence of arrhythmia in this patient population, then it's likely you're going to miss it. Especially in a vulnerable period when you've manipulated and blown up a balloon inside the aortic valve annulus which puts pressure and irritates the conduction system of the heart. So in a population that's already prone to arrhythmia, when you get in there and do things, there's a reason why these various valve procedures carry a significant pacemaker rate with them.

Remote monitoring allows us to identify these things before they become a problem and potentially put the patient at risk.

Do your patients easily accept that they need to wear a remote cardiac monitor? How do you explain it?

Dr. Gray: I explain that the likelihood of them having AFib, flutter, heart block, etc., with the disease process that they're being treated for right now is high, even if they don't have this procedure. One of the complications involved with the procedure is the need for pacemaker, as TAVR can induce heart block. I tell them that when we’re discussing the risks, benefits, and complications. We say that we're going to monitor their heart after the procedure to ensure that something's not happening later. And we make sure that we monitor them for 30 days to prevent them from having complications. It's part of the way we run our program. Not one person has had any hesitation; I think they feel reassured. 

Caution: U.S. federal law restricts this device to sale by or on the order of a physician.

1. Tian Y, Padmanabhan D, McLeod CJ, Zhang P, Xiao P, Sandhu GS, Greason KL, Gulati R, Nkomo VT, Rihal CS, et al. Utility of 30-day continuous ambulatory monitoring to identify patients with delayed occurrence of atrioventricular block after transcatheter aortic valve replacement. Circ Cardiovasc Interv. 2019;12:e007635. DOI: 10.1161/CIRCINTERVENTIONS.118.007635.