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Heart, Lung and Circulation

Dedicated Next Day Discharge Post Minimalist TAVI: The Tasmanian Experience

Published:October 19, 2022DOI:https://doi.org/10.1016/j.hlc.2022.09.011

      Objectives

      To assess the safety, feasibility and independent predictors of next day discharge (NDD) in patients undergoing minimalist transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) in a real-world Australian population.

      Methods

      This single centre study reviewed 135 consecutive patients who underwent minimalist transfemoral TAVI from June 2020 to February 2022. Baseline demographics, procedural characteristic and outcomes were obtained. All patients were assessed by the local protocol for NDD. Patients were then divided into two groups: those who achieved next day discharge (NDD) and those requiring >1 overnight hospital stay. Univariate, bivariate and stepwise multivariate logistic regression modelling was used to identify the predictors of successful next day discharge.

      Results

      The mean age of the cohort was 82.9±5.7 years with 62.3% patients male, the average STS score was 4.1±2.4. All 135 patients underwent a successful transfemoral TAVI procedure, with 131 (97%) receiving a balloon-expandable valve. Ninety-seven (97) (71.9%) patients achieved NDD. Thirty (30)-day outcomes were excellent with a 30-day mortality of 0.7%, transient ischaemic attack/cardiovascular accident (TIA/CVA) 1.5%, major vascular complication 1.5% and 11.4% need for permanent pacemaker (PPM). In patients not achieving NDD, the average length of stay (LOS) was 3.0 days. Baseline characteristics demonstrated pre-existing first degree atrioventricular (AV) block and right bundle branch block (RBBB) as statistically significant negative predictors of NDD on univariate analysis.
      Next day discharge was achievable in only 50% of patients who suffered any minor or major procedural complication (15/30). Stepwise multivariate logistic regression modelling demonstrated female gender (OR 3.094, 95% CI 1.141–8.391, p=0.026), smaller aortic valve area (AVA) (OR 48.265, 95% CI 2.269–102.6, p=0.013), the presence of diabetes mellitus (OR 0.594, 95% CI 0.356–0.991, p=0.046) and a longer procedure time (OR 0.960, 95% CI 0.935–0.986, p=0.002) as statistically significant negative predictors of NDD. In addition, there was no difference in 30-day readmission rates between the NDD and non-NDD cohort (7.2% vs 10.5%, p=0.386).

      Conclusion

      Next day discharge is safe and feasible in almost three quarters of patients undergoing minimalist TAVI for severe AS in a predominantly balloon expandable valve cohort, with a very low rate of 30-day readmission. NDD provides advantages for hospital efficiency and improved cost-effectiveness. Female gender, smaller AVA, the presence of diabetes mellitus and a longer procedure time were independent negative predictors of successful NDD.

      Keywords

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      References

        • Noad R.L.
        • Johnston N.
        • McKinley A.
        • Dougherty M.
        • Nzewi O.C.
        • Jeganathan R.
        • et al.
        A pathway to earlier discharge following TAVI: assessment of safety and resource utilization.
        Catheter Cardiovasc Interv. 2016; 87: 134-142
        • Ichobori Y.
        • Li J.
        • Davis A.
        • Patel T.M.
        • Lipinski J.
        • Panhwar M.
        • et al.
        Feasibility and safety of adopting next-day discharge as first-line option after transfemoral transcatheter aortic valve replacement.
        J Invasive Cardiol. 2019; 31: 64-72
        • Hamm C.W.
        • Mollmann H.
        • Holzhey D.
        • Beckmann A.
        • Veit C.
        • Figulla H.R.
        • et al.
        The German Aortic Valve Registry (GARY): in-hospital outcome.
        Eur Heart J. 2014; 35: 1588-1598
        • Holmes D.R.
        • Nishimura R.A.
        • Grover F.L.
        • Brindis R.G.
        • Carroll J.D.
        • Edwards F.H.
        • et al.
        Annual outcomes with transcatheter valve therapy: from the STS/ACC TVT registry.
        J Am Coll Cardiol. 2015; 66: 2813-2823
        • Hyman M.C.
        • Vemulapalli S.
        • Szeto W.Y.
        • Stebbins A.
        • Patel P.A.
        • Matsouaka R.A.
        • et al.
        Conscious sedation versus general anesthesia for transcatheter aortic valve replacement: insights from the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.
        Circulation. 2017; 136: 2132-2140
        • Bestehorn K.
        • Eggebrecht H.
        • Fleck E.
        • Bestehorn M.
        • Mehta R.H.
        • Kuck K.H.
        Volume-outcome relationship with transfemoral transcatheter aortic valve implantation (TAVI): insights from the compulsory German Quality Assurance Registry on Aortic Valve Replacement (AQUA).
        EuroIntervention. 2017; 13: 914-920
        • Attizzani G.F.
        • Alkhalil A.
        • Padaliya B.
        • Tam C.
        • Lopes J.P.
        • Fares A.
        • et al.
        Comparison of outcomes of transfemoral transcatheter aortic valve implantation using a minimally invasive versus conventional strategy.
        Am J Cardiol. 2015; 116: 1731-1736
        • Kamioka N.
        • Wells J.
        • Keegan P.
        • Lerakis S.
        • Binongo J.
        • Coorigan F.
        Predictors and clinical outcomes of next-day discharge after minimalist transfemoral transcatheter aortic valve replacement.
        JACC Cardiovasc Interv. 2018; 11: 107-115
        • Chacko Y.
        • Poon K.K.
        • Keegan W.
        • Natani S.
        • Tesar P.
        • Wall D.
        • et al.
        Outcomes of the first 300 cases of transcatheter aortic valve implantation at a high-volume Australian private hospital.
        Heart Lung Circ. 2020; 29: 1534-1541
        • Vriesendorp P.A.
        • Nanayakkara S.
        • Bowditch J.
        • Htun N.M.
        • Stub D.
        • Dagan M.
        • et al.
        Short- and long-term outcomes after transcatheter aortic valve implantation in public and private hospital settings: a propensity-matched analysis.
        Heart Lung Circ. 2021; 30: 1910-1917
        • Bennetts J.
        • Sinhal A.
        • Walters D.
        • MacIsaac A.
        • Fayers T.
        • Lo S.
        • Almeida A.
        • Muller D.W.M.
        2021 CSANZ and ANZSCTS position statement on the operator and institutional requirements for a transcatheter aortic valve implantation (TAVI) program in Australia.
        Heart Lung Circ. 2021; 30: 1811-1818
      1. Teleproctoring: helping patients with aortic stenosis through COVID-19. https://insightplus.mja.com.au/2021/1/teleproctoring-caring-for-patients-with-aortic-stenosis-through-covid-19/. Accessed July 09, 2022.

        • Thiele H.
        • Kurz T.
        • Feistritzer H.J.
        • Stachel G.
        • Hartung P.
        • Lurz P.
        • et al.
        General versus local anesthesia with conscious sedation in transcatheter aortic valve implantation: the randomized SOLVE-TAVI trial.
        Circulation. 2020; 142: 1437-1447
        • Wood D.
        • Lauck S.
        • Cairns J.
        • Humphries K.H.
        • Cook R.
        • Welsh R.
        • et al.
        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.
        J Am Coll Cardiol Intv. 2019; 12: 459-469
        • Watanabe Y.
        • Kozuma K.
        • Hioki H.
        • Kawashima H.
        • Nara Y.
        • Kataoka A.
        • et al.
        Pre-existing right bundle branch block increases risk for death after transcatheter aortic valve replacement with a balloon-expandable valve.
        JACC Cardiovasc Interv. 2016; 9: 2210-2216
        • Erkapic D.
        • De Rosa S.
        • Kelava A.
        • Lehmann R.
        • Fichtlscherer S.
        • Hohnloser S.H.
        • et al.
        Risk for permanent pacemaker after transcatheter aortic valve implantation: a comprehensive analysis of the literature.
        J Cardiovasc Electrophysiol. 2012; 23: 391-397
        • Muntané-Carol G.
        • Okoh A.K.
        • Chen C.
        • Nault I.
        • Kassotis J.
        • Mohammadi S.
        • et al.
        Ambulatory electrocardiographic monitoring following minimalist transcatheter aortic valve replacement.
        JACC Cardiovasc Interv. 2021; 14: 2711-2722
        • Reiter C.
        • Lambert T.
        • Kellermair J.
        • Blessberger H.
        • Fellner A.
        • Nahler A.
        • et al.
        Delayed total atrioventricular block after transcatheter aortic valve replacement assessed by implantable loop recorders.
        JACC Cardiovasc Interv. 2021; 14: 2723-2732
        • Fukutomi M.
        • Hokken T.
        • Wong I.
        • Bieliauskas G.
        • Daemen J.
        • de Jaegere P.
        • et al.
        Prophylactic permanent pacemaker strategy in patients with right bundle branch block undergoing transcatheter aortic valve replacement.
        Catheter Cardiovasc Interv. 2021; 98: E1017-E1025
        • Krishnaswamy A.
        • Sammour Y.
        • Mangieri A.
        • Kadri A.
        • Karrthik A.
        • Banerjee K.
        • et al.
        The utility of rapid atrial pacing immediately post-TAVR to predict the need for pacemaker implantation.
        JACC Cardiovasc Interv. 2020; 13: 1046-1054
        • Forrest J.K.
        • Adams D.H.
        • Popma J.J.
        • Reardon M.J.
        • Deeb G.M.
        • Yakubov S.J.
        • et al.
        Transcatheter aortic valve replacement in women versus men (from the US CoreValve Trials).
        Am J Cardiol. 2016; 118: 396-402
        • Kofler M.
        • Reinstadler S.J.
        • Stastny L.
        • Dumfarth J.
        • Reindl M.
        • Wachter K.
        • et al.
        EuroSCORE II and the STS score are more accurate in transapical than in transfemoral transcatheter aortic valve implantation.
        Interact Cardiovasc Thorac Surg. 2018; 26: 413-419
        • Chorin E.
        • Finkelstein A.
        • Banai S.
        • Aviram G.
        • Barkagan M.
        • Barak L.
        Impact of diabetes mellitus and hemoglobin A1C on Outcome after transcatheter aortic valve implantation.
        Am J Cardiol. 2015; 116: 1898-1903
        • Capodanno D.
        • Barbanti M.
        • Tamburino C.
        • D’Errigo P.
        • Ranucci M.
        • Santoro G.
        • et al.
        • OBSERVANT Research Group
        A simple risk tool (the OBSERVANT score) for prediction of 30-day mortality after transcatheter aortic valve replacement.
        Am J Cardiol. 2014; 113: 1851-1858
        • Genereux P.
        • Webb J.G.
        • Svensson L.G.
        • Kodali S.K.
        • Satler L.F.
        • Fearon W.F.
        • et al.
        Vascular complications after transcatheter aortic valve replacement: insights from the PARTNER (Placement of AoRTic TraNscathetER Valve) trial.
        J Am Coll Cardiol. 2012; 60: 1043-1052
        • Sun Y.
        • Liu X.
        • He Y.
        • Tang M.
        • Zhu Q.
        • Guo D.
        • et al.
        Meta-analysis of impact of diabetes mellitus on outcomes after transcatheter aortic valve implantation.
        Am J Cardiol. 2017; 119: 623-629
        • Nakashima M.
        • Watanabe Y.
        Transcatheter aortic valve implantation in small anatomy: patient selection and technical challenges.
        Interv Cardiol. 2018; 13: 66-68
        • Adams H.
        • Roberts-Thomson R.
        • Patterson T.
        • Prendergast B.
        • Redwood S.
        The low-risk tavi trials for severe aortic stenosis: future implications for Australian and New Zealand heart teams.
        Heart Lung Circ. 2020; 29: 657-661
        • Zhou J.Y.
        • Liew D.
        • Duffy S.J.
        • Walton A.
        • Htun N.
        • Stub D.
        Cost-effectiveness of transcatheter versus surgical aortic valve replacement in low-risk patients with severe aortic stenosis.
        Heart Lung Circ. 2021; 30: 547-554
        • Mendiz O.A.
        • Noč M.
        • Fava C.M.
        • Gutiérrez Jaikel L.A.
        • Sztejfman M.
        • Pleskovič A.
        • et al.
        Impact of cusp-overlap view for TAVR with self-expandable valves on 30-day conduction disturbances.
        J Interv Cardiol. 2021; 20219991528