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Predictors, safety of next-day discharge after TAVR confirmed
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Among patients who underwent minimalist transfemoral transcatheter aortic valve replacement without complications, next-day discharge was associated with similar 30-day outcomes and better 1-year outcomes vs. longer hospital stay, researchers reported.
Male sex, lack of atrial fibrillation, lower serum creatinine and younger age were among the predictors of next-day discharge in the cohort.
Norihiko Kamioka, MD, from the division of cardiology at Emory University School of Medicine, and colleagues analyzed patients who underwent minimalist transfemoral TAVR with a balloon-expandable valve (Sapien XT or Sapien 3, Edwards Lifesciences) at Emory between July 2014 and July 2016. Minimalist TAVR was defined as using conscious sedation, local anesthesia and transthoracic echocardiography guidance.
The researchers compared 30-day and 1-year mortality and readmission between those who had next-day discharge (n = 150) and those who had a longer hospital stay (n = 210). All underwent minimalist transfemoral TAVR with a balloon-expandable valve and had preprocedural CT with contrast. Median age was 81 years and Society of Thoracic Surgeons Predicted Risk of Mortality was 6.6%.
Predictors of early discharge
Kamioka and colleagues found the following were predictors of next-day discharge: male sex (OR = 2.02; 95% CI, 1.28-3.18), absence of AF (OR = 1.62; 95% CI, 1.02-2.57), serum creatinine (OR = 0.71; 95% CI, 0.55-0.92) and younger age (OR = 0.95; 95% CI, 0.93-0.98).
Among patients who had complications, 84% were not discharged the following day. After excluding patients who had complications, the researchers found no difference in mortality or readmission in 30 days between those discharged or not discharged the next day (HR = 0.62; 95% CI, 0.2-1.91).
However, at 1 year, those who had next-day discharge had lower risk for mortality or readmission compared with those who did not (HR = 0.47; 95% CI, 0.27-0.81).
The difference at 1 year was driven by lower risk for non-CV-related readmission in those with next-day discharge (HR = 0.31; 95% CI, 0.12-0.76), according to the researchers.
“Although superior outcomes are likely to be attributed to selected patient characteristics, [next-day discharge] in patients without in-hospital complications may be appropriate after transfemoral balloon-expandable TAVR,” Kamioka and colleagues wrote.
Usefulness unclear
In a related editorial, Molly Szerlip, MD, from the department of interventional cardiology at the Heart Hospital Baylor Plano, wrote that although the 30-day result is “helpful information, offering reassurance that patient safety is not being compromised,” the value of the 1-year result is unclear.
“One would not expect that whether the patient was discharged the next day or days 2, 3 or 4 following the procedure that any outcome other than short term would be affected,” she wrote. “The 1-year superior outcome for [next-day discharge] was driven only by a statistically significant reduction in noncardiovascular readmissions of the [next-day discharge] cohort. This merely emphasizes that the [next-day discharge] patients in this study were lower risk rather than that they benefited by [next-day discharge].” – by Erik Swain
Disclosures: Kamioka reports no relevant financial disclosures. Please see the study for the other authors’ relevant financial disclosures. Szerlip reports she has served as a proctor for Edwards Lifesciences and a speaker for Edwards Lifesciences and Medtronic.
Perspective
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Philippe Généreux, MD
These findings are very good news for the patient and are very important for health care because of the cost implications. The fact that TAVR can be performed safely enough to allow next-day discharge is very important, especially compared with surgical AVR, where the length of stay may be 5 to 10 days.
The results confirm what we do every day. In our program, we do our best to achieve next-day discharge after TAVR if there are no complications. We have to factor in variables such as whether they live independently and how sick they are. Even if they are moderate risk, they are often able to go home the next day. If they are extremely high risk due to factors such as high creatinine or HF, they will stay longer. Atrial fibrillation or other conditions that may require anticoagulation also tend to confer a longer stay, as these patients may be at high risk for bleeding. We have to be more careful with them. Also needing a longer stay are patients who had new left bundle branch block or transient complete block during the procedure, even if they did not require a pacemaker.
Additional good news from this study is that even if the patient needs to stay longer, there is no difference in long-term CV outcomes. While patients who stayed longer had higher risk for mortality or readmission at 1 year, driven by non-CV-related readmissions, we have to remember that longer length of stay usually means sicker patients. Those numbers are likely more a function of how sick the patient was before the procedure than of the safety of the TAVR procedure. We can be reassured that we can keep the patient 1 to 3 extra days if we need to.
We are now seeing same-day discharge occurring after TAVR in a very particular subset of patients. These tend to be lower-risk patients who had their procedure in the morning with no complications. They can be sent home on the same day after 8 to 12 hours of observation. I hope to see more publications about same-day discharge in the future.
This study covered only procedures with a balloon-expandable prosthesis. Future studies should examine whether the findings can be replicated with self-expanding prostheses. I suspect they probably can.
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