Abstract
Aim: Over the past decade, transcatheter aortic valve implantation (TAVI) has matured into a valid treatment strategy for elderly patients with severe aortic stenosis. TAVI programs will grow with its adoption in low-risk patients. The aim of this study was to evaluate safety and feasibility of early discharge protocols, either home or back to a referring hospital. Methods: Consecutive patients undergoing TAVI between July 2017 and July 2019 were stratified into three discharge pathways from TAVI center: (1) early home (EXPRES); (2) early transfer to referring hospital (R-EXPRES); and (3) routine discharge (standard). Baseline, procedural, and 30-day outcomes were prospectively collected and compared per discharge pathway. Results: In total, 22 (5%) patients were enrolled in the EXPRES cohort [median age 78 (IQR: 73-81); mean Society of Thoracic Surgeons (STS) 2.4% ± 1.5%], 121 (29%) in the R-EXPRES cohort [median age 81 (IQR: 77-84); mean STS 4.3% ± 2.8%], and 269 (65%) in the routine discharge cohort [median age 80 (IQR: 75-85); mean STS 4.4% ± 3.1%]. EXPRES patients trended to be younger (P = 0.13) and had lower STS (P = 0.02). Early clinical outcome was similar through the different pathways including re-hospitalization rate. Median length of stay was one day longer for R-EXPRES vs. routine discharge patients [5 (IQR: 4-7) vs. 4 (IQR: 3-6); P < 0.01]. Median length of stay (LOS) was two days (IQR: 1-3 days) for EXPRES patients. Conclusion: Early discharge pathways home and to referral hospitals are safe and help streamline TAVI programs. LOS in referring hospitals may be further reduced.
Highlights
Severe aortic stenosis is the most common valve disease requiring treatment in the Western world, and its prevalence is growing due to an ageing population[1]
For EXpedited discharge Program Rotterdam Erasmus MC (EXPRES) patients without a pacemaker at baseline, preferably an Edwards Sapien S3 (Edwards Lifesciences Corp., Irvine, California) or Acurate NEO (Boston Scientific, Marlborough, Massachusetts) valve was implanted because these transcatheter heart valve (THV) platforms seem associated with the lowest risk for high-degree conduction disorders[11,12]
A routine discharge pathway was followed in 269 patients (65%), while 121 patients were included in the R-EXPRES cohort (29%) and 22 in the EXPRES cohort (5%)
Summary
Severe aortic stenosis is the most common valve disease requiring treatment in the Western world, and its prevalence is growing due to an ageing population[1]. The only curative option for aortic stenosis is surgical or transcatheter valve implantation. Transcatheter aortic valve implantation (TAVI) is indicated for patients with a high or intermediate surgical risk[2,3]. Recent trials have shown TAVI feasibility in low surgical risk patients[4,5]. Every patient requiring a bioprosthesis for aortic stenosis should be informed about the transcatheter option. The European and North American annual TAVI volume is expected to increase from 180,000 to 270,000 cases per year[6]. Contemporary society guidelines recommend centralizing TAVI care in highvolume (> 85 procedures/year) sites because of an inverse volume-mortality correlation[7]. Home discharge protocols aim to limit in-hospital stay to fewer than three days after TAVI with favorable early and mid-term outcomes and no penalty for readmissions or delayed need for definite pacemakers[8]
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