Predictors of early discharge after transcatheter aortic valve implantation: insight from the CoreValve ClinicalService

Abstract

AimsThe aim of this study was to minimize the procedure, and reduce the length of hospital stay (LoS) is the future objective for transcatheter aortic valve replacement (TAVI).Aims of the study are to identify procedural and electrocardiographical predictors of fast-track discharge in patients who underwent TAVI.MethodsPatients treated with TAVI included in the One Hospital ClinicalService project were categorized according to the LoS. ‘Fast-Track’ population, with a postprocedural LoS less than or equal to 3 days, was compared with the ‘Slow-Track’ population with a postprocedural LoS greater than 3 days.ResultsOne thousand five hundred and one patients were collected. Despite single baseline characteristics being almost similar between the two groups, Slow-Track group showed a higher surgical risk (P < 0.001). Patients in the Slow-Track group were more frequently treated with general anaesthesia (P = 0.002) and less frequently predilated (P < 0.001) and received a lower amount of contrast media. No difference between Slow-Track and Fast-Track patients was observed at 30 days in death and in cardiovascular rehospitalization.In the multivariable analysis, STS score of at least 4% [odds ratio (OR): 1.64; P = 0.01], general anaesthesia (OR: 2.80; P = 0.03), predilation (OR: 0.45; P < 001), NYHA 3–4 at baseline (OR: 1.65; P = 0.01), AVB I/LBBB/RBBB onset (OR: 2.41; P < 0.001) and in-hospital new PM (OR: 2.63; P < 0.001) were independently associated with a higher probability of Slow-Track.ConclusionFast-Track patients were safely discharged home showing no difference in clinical outcomes after discharge up to 30 days compared with the Slow-Track group. The STS score, general anaesthesia, NYHA 3--4 at baseline, in-hospital onset of conduction disturbances and new PM implantation after TAVI turned out to be predictors of Slow-Track.

Transcatheter aortic valve implantation 20 years later: early discharge after transfemoral minimalist procedures as a proof of effectiveness

“…Major bleeding, often related to vascular access, remains an issue after TAVI and is associated with a higher probability of undergoing a prolonged postoperative hospitalization 14 . However, in this selected population of patients having received second-generation self-expandable devices with a smaller transfemoral approach carried out by experienced operators, the authors did not find any association between bleeding and longer LoS, against the background of a reassuringly low incidence of major vascular complications 13 …”

“…How can we contextualize the paper by Angelillis et al 13 in the current era of progressively increasing demand for TAVI procedures? The authors should be commended for having provided a glimpse into the contemporary effectiveness of self-expandable TAVI in high-volume Italian centers and their encouraging results, reporting a 3% incidence of 30-day major adverse events, mainly consisting of minor stroke/transient ischemia attack 13 .…”

“…How can we contextualize the paper by Angelillis et al 13 in the current era of progressively increasing demand for TAVI procedures? The authors should be commended for having provided a glimpse into the contemporary effectiveness of self-expandable TAVI in high-volume Italian centers and their encouraging results, reporting a 3% incidence of 30-day major adverse events, mainly consisting of minor stroke/transient ischemia attack 13 . They strengthen the evidence that enlarging the boundaries of LoS shortening in selected patients (Table 1), thanks to minimization of invasiveness, does not affect clinical outcomes, 24 and that the well known predictors of slower recovery must be borne in mind to anticipate the need for more intensive postprocedural care 25 .…”

“…In previous studies, indeed, the presence of a permanent pacemaker before TAVI was a variable associated with a clear reduction in LoS, [14][15][16] while the need for a new permanent pacemaker implantation (PPMI) after TAVI was associated with delayed discharge. 17 Noteworthy is that this study population consisted of only transfemoral TAVI patients, 13 which is known for being associated with higher rates of early discharge 18 and lower costs. 9 No significant difference between Fast-Track and Slow-Track groups was reported in procedural success (both >99%), in vascular complications (0.5% vs. 2.5%, P ¼ 0.11), in cardiovascular mortality (1.8% vs. 0.6%, P ¼ 0.09), in major cerebrovascular accidents (both 0.9%) and in hospital readmission (1.3% vs. 1.6%, P ¼ 0.99) at 30 days.…”

“…14 However, in this selected population of patients having received second-generation selfexpandable devices with a smaller transfemoral approach carried out by experienced operators, the authors did not find any association between bleeding and longer LoS, against the background of a reassuringly low incidence of major vascular complications. 13 How can we contextualize the paper by Angelillis et al 13 in the current era of progressively increasing demand for TAVI procedures? The authors should be commended for having provided a glimpse into the contemporary effectiveness of self-expandable TAVI in high-volume Italian centers and their encouraging results, reporting a 3% incidence of 30-day major adverse events, mainly consisting of minor stroke/transient ischemia attack.…”