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Outcomes worse with delayed discharge after transfemoral TAVR
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SAN DIEGO — Delayed hospital discharge after transfemoral transcatheter aortic valve replacement has declined in recent years, but it remains associated with worse short- and long-term outcomes, researchers reported at the Society for Cardiovascular Angiography and Interventions Scientific Sessions.
In an analysis of 24,285 patients who underwent transfemoral TAVR and survived to discharge in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy Registry (STS/ACC TVT Registry), the prevalence of delayed discharge — defined as longer than 72 hours after the procedure — decreased from 62% to 34.4% from 2011 to 2015 (P < .01). This downward trend was observed even when patients were stratified by STS risk score.
“This study is unique because, unlike other CV registries, all TAVRs must be reported to the STS/ACC TVT Registry, so these data pretty much represent national practice within the United States,” researcher Siddharth Wayangankar, MD, assistant professor of medicine at the University of Florida, said during a press conference. “Length of stay has significantly decreased, and with the continued refinement in techniques and patient selection, we anticipate this trend will not only continue but also improve.”
Wayangankar, a Cardiology Today Next Gen Innovator, and colleagues also evaluated 1-year outcomes in relation to length of stay. Stroke and MI rates were not statistically significantly different between the early and delayed discharge groups. However, all-cause mortality and bleeding requiring hospitalization were significantly higher at 1 year among the delayed discharge group. These two variables, he noted, primarily drove the composite outcome in favor of early discharge.
After adjustment for in-hospital and procedural complications, delayed discharge was a significant predictor of 1-year all-cause mortality (HR = 1.45; 95% CI, 1.3-1.6), and a similar effect was observed for 1-year bleeding events requiring hospitalization. Wayangankar also noted that the Kaplan-Meier curves separated early post-procedure and continued to diverge thereafter.
In multivariate analysis, the researchers also identified the following predictors of delayed discharge:
- age older than 85 years;
- black race or Hispanic ethnicity;
- previous mitral valve procedures;
- diabetes;
- home oxygen;
- atrial fibrillation;
- dialysis;
- chronic kidney disease;
- right ventricular systolic pressure greater than 60 mm Hg before the procedure;
- inability to do a walk test or taking more than 10 seconds to do a minute walk test; and
- use of a self-expanding valve.
Independent predictors of early discharge included prior pacemaker, prior implantable cardioverter defibrillator, prior MI, prior CABG, smoking, severe aortic insufficiency, valve-in-valve procedures and use of moderate sedation.
“The predictors from our study could have a huge impact on future clinical care of TAVR patients,” Wayangankar said in a press release. “Pre-TAVR, these predictors could be used to develop bedside risk scores for length of stay. These could help physicians in patient selection, procedural and post-procedural planning based on patient-specific variables. On a much bigger front, these risk scores could be used by administrators, third-party payers and policymakers for formulating coverage for TAVR procedures and evaluating bundle payments.” – by Melissa Foster
Reference:
Wayangankar S, et al. Late-Breaking Clinical Science II. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; April 25-28, 2018; San Diego.
Disclosure: Wayangankar reports he is a proctor for Medtronic Valve Therapies.