TAVR confers shorter stay, higher rate of home discharge vs. surgery

Patients who underwent transcatheter aortic valve replacement for the treatment of aortic stenosis via the nontransapical approach had a shorter length of stay and were more likely to be discharged home instead of a skilled nursing facility compared with patients who underwent surgical AVR, according to a study published in Circulation: Cardiovascular Interventions.

“The technical advancements in transcatheter technology and growing procedural experience are leading to continued improvements in outcomes with TAVR and a reduction in the use of postoperative health care resources,” Sameer Arora, MD, preventive medicine resident at University of North Carolina School of Medicine, and colleagues wrote.

National Inpatient Sample data

Researchers analyzed data from the National Inpatient Sample databases of patients with aortic stenosis aged at least 50 years who underwent elective surgical AVR (n = 7,266) or TAVR (n = 10,833) between January and September 2015.

The primary outcomes were length of stay and discharge disposition, which was categorized as transfer to short-term hospital, routine/home health care, death or transfer to skilled nursing facility, intermediate care facility or other care facility.

Of the patients who underwent TAVR, 16% underwent transapical TAVR and 84% underwent endovascular TAVR.

Compared with patients in the surgical AVR group, those in the TAVR group were more likely to be older (81 years vs. 70 years; P < .0001), to be women (45.8% vs. 38.7%; P < .0001) and to have a higher Charlson Comorbidity Index score (2.7 vs. 1.5; P < .0001).

The average length of stay between 2012 and 2015 declined for both the TAVR (6.3 days to 4.6 days; P < .0001) and surgical AVR groups (7.5 days to 6.8 days; P < .0001). The reduction was greater in patients who underwent TAVR (P < .0001).

There was an increase in home or home health care discharge in the TAVR group (2012, 67.7%; 2015, 77.4%; P < .0001), but not in the surgical AVR group (2012, 76.8%; 2015, 79.5%; P = .25).

After standardizing, patients who underwent TAVR had a significantly shorter length of stay (change in estimate, –2.93; 95% CI, –3.26 to –2.6) and were less likely to be transferred to a skilled nursing facility (OR = 0.45; 95% CI, 0.4-0.51) compared with patients who had surgical AVR. The difference in in-hospital mortality was not significant after standardization (OR = 0.85; 95% CI, 0.61-1.2).

Outcomes with different approaches

Compared with surgical AVR, patients who underwent TAVR through an endovascular approach had a lower average length of stay (change in estimate, –3.38; 95% CI, –3.72 to –3.05) and were less likely to be transferred to a skilled nursing facility (OR = 0.39; 95% CI, 0.34-0.44). Patients who underwent TAVR through a transapical approach had a slightly shorter length of stay (change in estimate, –0.6; 95% CI, –1.1 to –0.1) and a similar incidence of discharge to a skilled nursing facility (OR = 0.87; 95% CI, 0.73-1.03) compared with the surgical group.

“This confirms the current paradigm where transfemoral access for TAVR has emerged as the default strategy because of the better adverse effect profile and feasibility to perform TAVR under conscious sedation with the sole use of transthoracic echocardiography,” Arora and colleagues wrote. “The results of this study are even more applicable today than they were at the time of this study population, as the rate of transapical access has reduced dramatically.”

In a related editorial, Adedapo Iluyomade, MD, MBA, fellow in cardiovascular disease at University of Miami, and Mauricio G. Cohen, MD, associate professor of medicine and director of the cardiac catheterization laboratory at University of Miami Health System, wrote: “With bundled payment systems emerging, and outcomes for TAVR and [surgical] AVR converging, especially in intermediate- and low-risk populations, investigating the economic impact of practice changes, patient preferences and financial incentives should be a major goal as TAVR continues to rapidly evolve and its indications expand. Further research in this field will inevitably enhance our decision-making capacity and spur new advances in technology, minimalist approaches and policies.” – by Darlene Dobkowski

Disclosure s : The authors and Iluyomade report no relevant financial disclosures. Cohen reports he is a consultant for Medtronic and received research support from Boston Scientific and Edwards Lifesciences.