麻豆传媒

Same-day discharge (SDD) after transcatheter aortic valve replacement (TAVR) in highly selected patients appeared safe in the PROTECT TAVR experience, among centers that had already been doing next-day discharge.

Faced with the pandemic strain on healthcare systems worldwide, seven centers in Canada, the U.S., and the U.K. opted to try SDD in order to maintain TAVR volumes while preserving hospital resources during COVID-19 case surges. From March 2020 to August 2021, 5.9% of their 2,100 patients who underwent elective transfemoral TAVR during morning hours were selected for SDD.

For this SDD cohort, the combined incidence of cardiovascular death, stroke, myocardial infarction, all-cause readmission, major vascular complications, and new permanent pacemaker (PPM) implantation at 30 days was 5.7% -- a respectable number, according to investigators led by David Wood, MD, of St. Paul's and Vancouver General Hospital and the University of British Columbia.

Incidence was driven by readmissions (half of which were cardiovascular-related). The only death followed a spontaneous subarachnoid hemorrhage in a patient on anticoagulation for atrial fibrillation,

Importantly, no patient required a PPM between SDD and 30-day follow-up, the investigators reported in .

Their multicenter report expanded on prior case series demonstrating SDD's feasibility in single hospitals. "Given the encouraging safety outcomes of this study, SDD may have an ongoing role in highly selected patients as the COVID-19 pandemic abates," Wood's group suggested.

"The arrival of COVID-19-associated hospital bed and resource shortages, coupled with the recent implementation of shorter hospital stays post-TAVR, created the perfect environment for a concept that would have seemed outlandish only a few short years ago: SDD post-TAVR," according to Jay Giri, MD, MPH, and Paul Fiorilli, MD, both of the Hospital of the University of Pennsylvania in Philadelphia.

"The low incidence of the primary outcomes provides initial support for the concept of SDD in patients with similar baseline and procedural characteristics at other experienced TAVR centers. The selection criteria of patients included, and the practices employed in these studies lay a roadmap for the broader implementation of an SDD strategy after TAVR," Giri and Fiorilli wrote in an .

The seven participating hospitals, all already experienced in next-day discharge after TAVR, sought SDD candidates who were at low risk for vascular complications and postoperative conduction abnormalities. Patients were required to have adequate social support and either virtual or in-person access to the TAVR program in case of readmission.

SDD was predicated on the absence of vascular complications, bleeding, and conduction disease.

Operators followed the principles of minimalist TAVR, and patients bypassed critical care monitoring after the procedure. An EKG was performed immediately postprocedure and again at 4 hours to assess for new conduction abnormalities. At that point, if there was adequate vascular access hemostasis, the patient was eased back onto his or her feet with the help of a nurse.

All patients underwent complete transthoracic echocardiogram (TTE) prior to discharge, either on the table or in the recovery unit. Some went home with an extended event monitor, at the clinician's discretion. Patients had virtual or in-person follow-up appointments with their TAVR team on postdischarge day 1. Standard follow-up TTE was performed by a local referring provider or by the TAVR center on postdischarge day 30.

For SDD to go mainstream, Giri and Fiorilli suggested that there would need to be more reassurance that SDD protocols do not miss opportunities to intervene in case of periprocedural stroke, the risk of which remains elevated for 48 hours after TAVR.

Yet in practical terms, money could end up being the real barrier.

"[I]f outpatient coding that reimburses significantly lower than current inpatient diagnosis-related group codes were to emerge for TAVR, this would actually be counterproductive to hospital finances despite the perceived efficiencies created by SDD. This could well exacerbate the already existing inequities in access to TAVR faced by rural, minority, and socioeconomically disadvantaged populations," the editorialists warned.

Wood's group reported that their SDD cohort averaged 78.9 years old, and 29% were women. Median STS score was 2.4%. Nearly a third had preexisting pacemakers.

TAVR utilized balloon-expandable valves in 96.8% of cases.

There were no major vascular complications, strokes, or deaths during the index admission. One patient required PPM implantation for complete heart block (after receiving a self-expanding valve) and was still discharged the same day. Otherwise, there were no new conduction abnormalities post-TAVR.

Wood and colleagues cautioned that their findings may not be generalized to the broader transfemoral TAVR population, and that reasons for exclusion from SDD were not recorded or included in the study.

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