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Background Transcatheter aortic valve implantation (TAVI) is a widely adopted procedure for patients with severe aortic stenosis (AS). 1 The requirement for packed red cell (PRC) transfusion post TAVI can significantly impact patient outcomes and resource management. In Glenfield Hospital, our standard of practice is to cross-match all TAVI patients with 4 units over the last decade, recently however, with a 3-fold increase in our TAVI procedures from 182 in 2021 to 543 in 2024, an average of 10 - 15 TAVIs performed weekly, cross-matching 4 units for 15 patients weekly exerts an enormous workload and cost on our blood transfusion department while also meeting the demands from other specialities. In 2013, 2 units of cross-matched PRC cost £294.60 as per published data2 and this cost is even higher now considering inflation.3–5 Early study from our centre presented at PCR London valve in November 2024 demonstrated that 5.9% (111/1878) of TAVI patients required PRC transfusion following TAVI between 1stJanuary 2013 and 31stJanuary 2024 and 1.38% (26/1878) required more than 2 units. Hence, we started cross-matching non-surgical transfemoral TAVI patients with 2 units since June 2024. As with other surgical specialty,6 cost reduction is achievable with the incorporation of latest evidence into our practice.Objective To assess the rate of blood transfusion in TAVI patients and to assess if our new practice of cross- matching 2 units of PRC for non-surgical transfemoral TAVIs is safe and cost effective following change in practice.Methods A retrospective study of all patients undergoing TAVIs at Glenfield Hospital Leicester, United Kingdom between 1 st of June and 31st of December 2024. Data were collected from the National Institute of Cardiovascular Outcome Research (NICOR) TAVI database and analysed retrospectively. Non-surgical access TAVI is defined as transfemoral TAVIs without arterial cut-down whereas the surgical access TAVIs include surgical cut-down of femoral artery, subclavian, direct aortic and transapical TAVIs and cross-matching 4 units remains for these cohorts as well as those with presence of antibodies. Since November 2024, our blood transfusion department stopped processing cross-matching requests for TAVI patients except in those with presence of antibodies however, they still continue to perform group & save as per protocol.Results A total of 312 TAVI procedures were completed during the 6 months period, mean age 81 ± 6 years, 39% were female [ table 1]. TAVI was performed for severe AS in 94% of patients and 91% of TAVIs were performed due to degenerative native aortic valve disease and 7.5% as valve-in-valve TAVIs. 28% were diabetic, 9% and 7% had a previous history of stroke and transient ischaemic attack respectively, 27% had history of atrial fibrillation/atrial flutter and 5% have severely impaired left ventricular systolic function (ejection fraction, EF < 35%). Majority of cases (94%) were non-surgical transfemoral TAVI, and required local anaesthesia [table 2]. A self-expanding valve was implanted in 52% of patients with the remainder being balloon-expanding valve. Balloon pre-dilation of the aortic valve was achieved in 29% of patients whereas post-dilation was 1%. The mean procedure time was 66 ± 25 mins. Vascular closure device was used to achieve haemostasis in 93% of cases. During the 6 months of study, 4 patients (1.28%) required PRC transfusion following TAVI and only 1 patient (0.32%) required > 2 units of PRC transfusion. This was a patient who required emergency surgical repair and closure of femoral access following failure of vascular closure device. Since November 2024, our blood transfusion department stopped processing cross-matching requests for TAVIs patients except in those with presence of antibodies however, they still continue to perform group & save as per protocol.Conclusion To enhance patient safety in non-surgical TAVI patients, a group & save and/or cross-matching 2 units of PRC is safe and is associated with cost reduction.Abstract 2-021 Table 1Showing patients baseline characteristics Patient characteristics Number (%), n = 312 Age81 ± 6Female122 (39%) EthnicityCaucasianBlackAsian297 (95.5)1 (0.5)13 (4) Procedure urgencyElectiveUrgent241 (77)73 (23)Body mass index, BMI28 ± 5Heart Team MDT performed312 (100)Diabetes89 (28) Smoking statusCurrent smokerEx-smokerNever smoked14 (4)176 (56)122 (39) Pulmonary diseaseAsthmaCOPDILD28 (9)44 (14)20 (6) Neurological diseaseStrokeTIA29 (9)22 (7)Previous MI29 (9)Creatinine, mmol/L (IQR)92 (77, 116) Heart rhythmSinusAF/flutterPacedUnknown194 (62)85 (27)30 (10)3 (1) Aortic valve pathologyStenosisRegurgitationMixed294 (94)6 (2)12 (4) Aortic valve aetiologyDegenerativeBioprostheticRheumaticCongenital284 (91)25 (7.5)2 (1)1 (0.5) Pre TAVI echo parametersPeak gradient, mmHgMean gradient, mmHgValve area, cm²70 ± 2441 ± 160.78 ± 0.29 LV systolic functionPreserved, EF > 55%Impaired, EF 35 – 49%)Poor, EF < 35%240 (77)55 (18)17 (5)Abstract 2-021 Table 2Showing patients procedural characteristics Procedural characteristics Number (%), n = 312 Delivery approachTransfemoralFemoral (surgical cut down)SubclavianDirect aorticTrans apical294 (94)1 (0.5)10 (3)6 (2)1 (0.5)Procedure time, mins66 ± 25 AnaesthesiaGeneralLocal18 (6)294 (94) Valve platformMedtronic, EvolutFX/FX+ Edwards, S3Ultra/RESILIA MerilMyVal, Octacor Boston,Acurate Neo 2Biosensor, Allegra112 (36)97 (31)53 (17)42 (13)8 (3) Valve size20 – 2324 – 2729 – 3485 (27)136 (44)91 (29)Balloon pre-dilation prior to TAVI91 (29)Post-dilation after TAVI3 (1) Vascular closure techniqueDevice closureSurgical closure (planned)Surgical closure (bailout)291 (93)18 (6)3 (1) Post TAVI echo parametersPeak gradient, mmHgMean gradient, mmHgValve area, cm²17 ± 98 ± 52.02 ± 0.55 Blood transfusion post TAVINone1 unit2 unit5 unit306 (98.71)1 (0.32)2 (0.65)1 (0.32) Permanent pacemaker implantationNonePost TAVIProphylactic pre TAVI251 (80)28 (9)33 (11) Antiplatelet therapy on dischargeAspirin onlyAspirin + ClopidogrelAspirin + TicagrelorClopidogrel only126 (40)14 (4)1 (0.5)48 (15) Antithrombotic therapy on dischargeWarfarinNOAC11 (4)117 (38)References Leon MB, Smith CR, Mack M, Miller C, Moses JW, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597–1607.Hildebrand DR, Binnie NR, Aly EH. Is routine blood cross-matching necessary in elective laparoscopic colorectal surgery? Int J Surg. 2012;10(2):92–95.Blood and Components – Cost per Item. https://nhsbtdbe.blob.core.windows.net/umbraco- assetscorp/34945/price_list_bc_cost per-item_2024-25.pdfNHS Blood and Transplant - Blood component portfolio and prices. https://hospital.blood.co.uk/components/portfolio and-prices/Charges For Blood and Blood Derivatives Supplied to Non-Health Service Hospitals 2024–25. https://www.health-ni.gov.uk/sites/default/files/publications/health/doh-hscf-13-2024.PDF Hall TC, Pattenden C, Hollobone C, Pollard C, Dennison AR. Blood transfusion policies in elective general surgery: how to optimise cross-match-to-transfusion ratios. Transfus Med Hemother. 2013;40(1):27–31.