Referring hospital involvement in early discharge post transcatheter aortic valve implantation: the TAVI (R-) EXPRES program

Abstract

Aim: Over the past decade, transcatheter aortic valve implantation (TAVI) has matured into a valid treatment strategy for elderly patients with severe aortic stenosis. TAVI programs will grow with its adoption in low-risk patients. The aim of this study was to evaluate safety and feasibility of early discharge protocols, either home or back to a referring hospital.

Methods: Consecutive patients undergoing TAVI between July 2017 and July 2019 were stratified into three discharge pathways from TAVI center: (1) early home (EXPRES); (2) early transfer to referring hospital (R-EXPRES); and (3) routine discharge (standard). Baseline, procedural, and 30-day outcomes were prospectively collected and compared per discharge pathway.

Results: In total, 22 (5%) patients were enrolled in the EXPRES cohort [median age 78 (IQR: 73-81); mean Society of Thoracic Surgeons (STS) 2.4% ± 1.5%], 121 (29%) in the R-EXPRES cohort [median age 81 (IQR: 77-84); mean STS 4.3% ± 2.8%], and 269 (65%) in the routine discharge cohort [median age 80 (IQR: 75-85); mean STS 4.4% ± 3.1%]. EXPRES patients trended to be younger (P = 0.13) and had lower STS (P = 0.02). Early clinical outcome was similar through the different pathways including re-hospitalization rate. Median length of stay was one day longer for R-EXPRES vs. routine discharge patients [5 (IQR: 4-7) vs. 4 (IQR: 3-6); P < 0.01]. Median length of stay (LOS) was two days (IQR: 1-3 days) for EXPRES patients.

Conclusion: Early discharge pathways home and to referral hospitals are safe and help streamline TAVI programs. LOS in referring hospitals may be further reduced.

Keywords

Aortic valve stenosis / transcatheter aortic valve implantation / early discharge / length of stay

References

[1] Osnabrugge RL,Head SJ.Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling study.J Am Coll Cardiol2013;62:1002-12

[2] Baumgartner H,Bax JJ.ESC Scientific Document Group2017 ESC/EACTS Guidelines for the management of valvular heart disease.Eur Heart J2017;38:2739-91

[3] Nishimura RA,Bonow RO.2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol2017;70:252-89

[4] Mack MJ,Thourani VH.PARTNER 3 InvestigatorsTranscatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med2019;380:1695-705

[5] Popma JJ,Yakubov SJ.Evolut Low Risk Trial InvestigatorsTranscatheter aortic-valve replacement with a self-expanding valve in low-risk patients.N Engl J Med2019;380:1706-15

[6] Durko AP,Van Mieghem NM.Annual number of candidates for transcatheter aortic valve implantation per country: current estimates and future projections.Eur Heart J2018;39:2635-42

[7] Vemulapalli S,Mack MJ.Procedural volume and outcomes for transcatheter aortic-valve replacement.N Engl J Med2019;380:2541-50

[8] Lauck SB,Baumbusch J.Vancouver transcatheter aortic valve replacement clinical pathway: minimalist approach, standardized care, and discharge criteria to reduce length of stay.Circ Cardiovasc Qual Outcomes2016;9:312-21

[9] Wood DA,Cairns JA.The Vancouver 3M (Multidisciplinary, Multimodality, But Minimalist) Clinical pathway facilitates safe next-day discharge home at low-, medium-, and high-volume transfemoral transcatheter aortic valve replacement centers: The 3M TAVR Study.JACC Cardiovasc Interv2019;12:459-69

[10] Barbanti M,Spence MS.Optimising patient discharge management after transfemoral transcatheter aortic valve implantation: the multicentre European FAST-TAVI trial.EuroIntervention2019;15:147-54

[11] Abdel-Wahab M,Frerker C.CHOICE investigatorsComparison of balloon-expandable vs self-expandable valves in patients undergoing transcatheter aortic valve replacement: the CHOICE randomized clinical trial.JAMA2014;311:1503-14

[12] Toggweiler S,Mogensen B.Very low pacemaker rate following ACURATE neo transcatheter heart valve implantation.EuroIntervention2017;13:1273-80

[13] Kappetein AP,Généreux P.Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document.Eur Heart J2012;33:2403-18

[14] Wayangankar SA,Xiang Q.Length of stay after transfemoral transcatheter aortic valve replacement: an analysis of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.JACC Cardiovasc Interv2019;12:422-30

[15] Dall'Ara G,Moat N.Transcatheter Valve Treatment Sentinel Registry (TCVT) Investigators of the EurObservational Research Programme (EORP) of the European Society of CardiologyLocal and general anaesthesia do not influence outcome of transfemoral aortic valve implantation.Int J Cardiol2014;177:448-54

[16] Ehret C,Foldenauer AC.Is local anaesthesia a favourable approach for transcatheter aortic valve implantation?.BMJ Open2017;7:e016321 PMCID:PMC5623571

[17] Saint S,Kowalski CP,Hofer TP.Preventing catheter-associated urinary tract infection in the United States: a national comparative study.JAMA Intern Med2013;173:874-9 PMCID:PMC3665614

[18] Lansky AJ,Tchetche D.A prospective randomized evaluation of the TriGuard™ HDH embolic DEFLECTion device during transcatheter aortic valve implantation: results from the DEFLECT III trial.Eur Heart J2015;36:2070-8

[19] Nombela-Franco L,Morrison-Polo G.Incidence, causes, and predictors of early (≤30 days) and late unplanned hospital readmissions after transcatheter aortic valve replacement.JACC Cardiovasc Interv2015;8:1748-57

[20] Kolte D,Sardar MR.Thirty-day readmissions after transcatheter aortic valve replacement in the United States: insights from the nationwide readmissions database.Circ Cardiovasc Interv2017;10:e004472

[21] van der Boon RM,Benitez LM.Frequency, determinants and prognostic implications of infectious complications after transcatheter aortic valve implantation.Am J Cardiol2013;112:104-10

[22] Tirado-Conte G,Nombela-Franco L.Incidence, causes, and impact of in-hospital infections after transcatheter aortic valve implantation.Am J Cardiol2016;118:403-9

[23] Ream K,Valle J.Ambulatory rhythm monitoring to detect late high-grade atrioventricular block following transcatheter aortic valve replacement.J Am Coll Cardiol2019;73:2538-47

[24] Tang GHL,Michev I.“Cusp-overlap” view simplifies fluoroscopy-guided implantation of self-expanding valve in transcatheter aortic valve replacement.JACC Cardiovasc Interv2018;11:1663-5