Rationale, development, implementation, and initial results of a fast track protocol for transfemoral transcatheter aortic valve replacement (TAVR)

Abstract

Background: The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particularly in the US, was initially based on open surgical techniques and often includes general anesthesia, transesophageal echocardiographic monitoring, and cardiothoracic intensive care unit (ICU) stays. Whether a subgroup of patients could benefit from early extubation, fewer days in the ICU, and early ambulation in terms of both cost and effectiveness is unknown. Methods and Results: A fast track (FT) protocol was initiated at two institutions in our health system with specific inclusion criteria. Patients with complications or morbidity post procedure deemed ineligible to continue on the FT pathway were designated as deviations. Baseline characteristics, success and deviations, subsequent course, and direct costs were compared for FT eligible and ineligible patients over a 6-month study period. Among 99 patients undergoing Transfemoral TAVR, 39 (39%) met FT inclusion criteria. The mean age of eligible and ineligible patients was similar at 85 years, but by design, eligible patients had fewer co-morbid conditions. Successful completion of the FT protocol was achieved in 28 patients (72%). Patients on the FT had shorter ICU stays (28 6 103 vs 45 6 46 hours, P < 0.0001) and post-operative length of stay (4.3 6 4.4 vs 7.2 6 5.3 days, P < 0.0001), and incurred lower direct costs ($44,923 6 $14,187 vs $56, 339 6 17,808, P < 0.0001). Conclusions: It is feasible to identify a large percentage of suitable patients preprocedure who are eligible for a FT postprocedure care pathway. There was no evidence for compromise of care and successful completion of the pathway was associated with shorter length of stay and fewer direct costs. V C 2014 Wiley Periodicals, Inc.

Cost-Effectiveness of Transcatheter Aortic Valve Replacement With a Self-Expanding Prosthesis Versus Surgical Aortic Valve Replacement

“…The centers performing TAVR in the CoreValve U.S. trial were all new to the intervention, and extra precautions may have been taken in the context of an investigational device exemption trial. It is reasonable to expect that iterative improvements in TAVR technology in the short to intermediate term, coupled with increased clinical experience, will lead to reduced complication rates (21), more efficient care (22), reduced costs (23), and improved cost-effectiveness relative to SAVR, a much more mature therapy.…”

Vancouver Transcatheter Aortic Valve Replacement Clinical Pathway

“…In a study of EDC (≤3 days) after TF TAVR with the SAPIEN XT prosthesis, no significant difference in the combined primary end point of 30-day death and rehospitalization was found between the early and late discharge groups. 8 Marcantuono et al 32 reported the implementation of a preassigned fast track TF TAVR protocol with the achievement of shorter LOS of 3.8 days compared with their center's 7.2 days for standard care.…”

One-Year Clinical Outcomes With SAPIEN 3 Transcatheter Aortic Valve Replacement in High-Risk and Inoperable Patients With Severe Aortic Stenosis

“…Several recent studies and registries from outside the United States have demonstrated the feasibility, safety, and cost savings associated with the avoidance of general anesthesia and implementation of fast-track protocols. 15,16 Increased use of these minimalist approaches to transfemoral TAVR, particularly well suited to SAPIEN 3, may represent an opportunity to further improve outcomes with this device in the current era. Alternatively, it is possible that the high use of transesophageal echocardiography guidance for sizing and postimplantation optimization contributed to the observed high success rates.…”