Abstract
BACKGROUND: Sustained transcatheter aortic valve implantation (TAVI) program success requires processes of care to support careful case selection, determine peri-procedural requirements, facilitate early recovery and decrease length of stay. The Vancouver Program initiated multidisciplinary and multimodality risk stratification to determine patients’ suitability for a transfemoral (TF) minimalist peri-procedural approach, and implemented risk-stratified clinical pathways to facilitate discharge and reduce length of stay. METHODS: Standardized and streamlined screening was implemented to conduct multimodality assessments, including cardiac catheterization, transthoracic echocardiography, computed tomography, functional assessment and medical consultations. Following multidisciplinary eligibility decision for TF TAVI by the Heart Team, additional risk stratification was discussed to determine individuals’ appropriateness for a peri-procedural minimalist approach and/or early discharge. Risk-stratified clinical pathways were developed to support the patient cohorts. RESULTS: In 2013, 144 consecutive patients were accepted for TF TAVI and assigned to risk-stratified protocols (see Table 1). The mean age was 82 7 years, with the proportion of women ranging from 37% to 42% in the four cohorts, and mean STS risk scores between 6.3 and 7.1. The burden of comorbidities and functional impairment was similar across groups. The overall in-hospital outcomes included 2.1% mortality, 0% myocardial infarction, 0.7% stroke, 2.1% life threatening bleeding, 0.7% new dialysis, and 4.2% conduction disturbances requiring a new permanent pacemaker. Risk-stratified outcomes are presented in Table 1. The median length of stay for all patients was 3 days (IQR 2-3), 2 days (IQR 1-3) in the Awake cohort and 2 (IQR 1-2) in the Early Discharge cohort; 95.8% of patients were discharged home. The 30-day all-cause hospital readmission rate was 11.1%, ranging from 7% and 8% in the Awake and Early Discharge cohorts respectively, to 13% in the GA/TEE and Regular Discharge cohorts; no new deaths occurred between discharge and 30 days. CONCLUSION: The refined understanding of TAVI risk profiles and their mitigation with improved case selection, imaging, procedural expertise and clinical pathways offer opportunities to improve outcomes while ensuring patient safety and the sustained success of TAVI programs. Early experience with TAVI risk stratification, individualized procedure planning and tailored clinical pathways supported by multimodality screening and multidisciplinary case selection and care results in excellent outcomes and optimized length of stay. Canadian Pediatric Cardiology Association (CPCA) Oral SURGERY AND INTERVENTIONAL CATHETERISM IN CONGENITAL HEART DISEASE Sunday, October 26, 2014
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