Risk Stratification and Clinical Pathways to Optimize Length of Stay After Transcatheter Aortic Valve Replacement

doi:10.1016/j.cjca.2014.07.012

Canadian Journal of Cardiology

Volume 30, Issue 12, December 2014, Pages 1583-1587

https://doi.org/10.1016/j.cjca.2014.07.012 Get rights and content

Abstract

Background

Transcatheter aortic valve replacement (TAVR) program experience and advances present opportunities to introduce minimalist clinical pathways. The purpose of this study was to determine the safety and feasibility of preprocedural individualized risk stratification for general anaesthesia and transesophageal echocardiography (GA/TEE) or awake TAVR and the postprocedural standard or rapid discharge TAVR clinical pathways.

Methods

Standardized screening and multidisciplinary heart team consensus was used to evaluate individual periprocedural risk and requirements. Postprocedural clinical status and criteria guided the timing of discharge. We evaluated standardized TAVR outcomes and length of stay according to periprocedural practice and postprocedural trajectory.

Results

In 144 consecutive patients who underwent TAVR in 2013 (mean age, 82.0 ± 7.1 years; 38.2% women; mean Society of Thoracic Surgeons score, 6.5% ± 4.1%), 101 (69.1%) were assigned to the GA/TEE protocol, whereas 43 (29.9%) were assigned to the minimalist awake TAVR protocol. Irrespective of mode of anaesthesia, 94 (65.3%) patients were discharged within the standard time, whereas 50 (34.7%) patients were suitable for rapid discharge. Overall outcomes at 30 days were 2.1% mortality, 1.4% stroke, and 2.1% life-threatening bleeding. Median length of stay was shortest in the awake TAVR group (2 days; interquartile range [IQR], 1-3 days) and rapid discharge group (2 days; IQR, 1-2 days) and longer in the GA/TEE and standard discharge (3 days, IQR, 3-4 days) groups.

Conclusions

Excellent outcomes and decreased length of stay can be achieved with individualized risk stratification to select the optimal periprocedural practice and determine the timing of discharge. These findings should be further evaluated in a large long-term clinical study.

Résumé

Introduction

L’expérience et les avancées du programme de remplacement valvulaire aortique par cathétérisme (RVAC) permettent d’introduire des protocoles cliniques minimalistes. Le but de cette étude était de déterminer l’innocuité et la faisabilité de la stratification personnalisée du risque préinterventionnel concernant l’anesthésie générale et l’échocardiographie transœsophagienne (AG/ETO) ou le RVAC sans anesthésie générale et les protocoles cliniques postinterventionnels de sortie standard ou de sortie précoce d’hôpital après le RVAC.

Méthodes

Le dépistage standardisé et le consensus de l’équipe multidisciplinaire en cardiologie ont été utilisés pour évaluer le risque et les exigences individuels péri-interventionnels. L’état et les critères cliniques postinterventionnels ont permis de déterminer le moment de la sortie d’hôpital. Nous avons évalué les résultats standardisés du RVAC et la durée du séjour selon la pratique péri-interventionnelle et la trajectoire postinterventionnelle.

Résultats

Parmi les 144 patients consécutifs ayant subi le RVAC en 2013 (âge moyen, 82,0 ± 7,1 ans; 38,2 % de femmes; score moyen de la Society of Thoracic Surgeons, 6,5 % ± 4,1 %), 101 (69,1 %) ont été intégrés dans le protocole d’AG/ETO, tandis que 43 (29,9 %) ont été intégrés dans le protocole minimaliste de RVAC sans anesthésie générale. Quel que soit le mode d’anesthésie, 94 (65,3 %) patients ont obtenu leur sortie d’hôpital dans les délais standards, tandis que 50 (34,7 %) patients étaient aptes à obtenir une sortie précoce d’hôpital. Les résultats globaux à 30 jours étaient de 2,1 % de mortalité, 1,4 % d'accident vasculaire cérébral et 2,1 % d'hémorragie mettant en danger la vie. La durée médiane du séjour a été plus courte dans le groupe de RVAC sans anesthésie générale (2 jours; intervalle interquartile [IIQ], 1-3 jours) et le groupe ayant obtenu une sortie précoce d’hôpital (2 jours; IIQ, 1-2 jours) et plus longue dans les groupes d’AG/ETO et de sortie standard d’hôpital (3 jours, IIQ, 3-4 jours).

Conclusions

Les excellents résultats et la diminution de la durée du séjour peuvent être atteints par la stratification personnalisée du risque afin de choisir la meilleure pratique péri-interventionnelle et de déterminer le moment de la sortie d’hôpital. Ces résultats devraient être évalués davantage au cours d’une étude clinique d’envergure à long terme.

Section snippets

Standardized screening

The eligibility decision and risk stratification was a multidisciplinary consensus opinion of the heart team with representation from interventional cardiology, cardiac surgery, and nursing services, inclusive of the recommendations of imaging specialists and anaesthesiology, geriatric medicine, and other specialty services when appropriate. Standard diagnostic components included transthoracic echocardiography (TTE), coronary angiography, aortography, iliofemoral angiography, and computed

Results

The outcomes and process indicators of the program are evaluated and reported by Cardiac Services BC within the Provincial THV Program according to standardized international definitions.²¹ In 2013, 183 procedures—including 134 transfemoral (TF) native valves, 10 TF valve-in-valve procedures, and 39 alternative surgical approach procedures—were completed. After risk stratification of the 144 TF TAVR cohort (native and valve-in-valve), 101 (69.1%) followed the GA/TEE protocol and 43 (29.9%) were

Discussion

After encouraging results of early clinical trials, there has been an emergence of improved devices and procedural techniques and the development of international consensus guidelines and recommendations.22, 23, 24 TAVR has rapidly become the standard of care in high-risk patients.²⁵ Ongoing research indicates that broader indications may emerge.² Evidence is emerging about TAVR-specific risks,²⁶ but clinicians lack guidance to determine patients' periprocedural and discharge risks and the

Disclosures

Danny Dvir, Sandra Lauck, David Wood and Jian Ye are consultants to Edwards Lifesciences. Dion Stub is a consultant to St. Jude Medical. John Webb is a consultant to Edwards Lifesciences, St. Jude Medical, and Abbott Inc. Anson Cheung is consultant to Edwards Lifesciences, St. Jude Medical, HeartWare, and Neovasc.

References (26)

M.B. Leon et al.
Challenges and future opportunities for transcatheter aortic valve therapy
Prog Cardiovasc Dis
(2014)
W.R. Davies et al.
European experience and perspectives on transcatheter aortic valve replacement
Prog Cardiovasc Dis
(2014)
S. Toggweiler et al.
5-year outcome after transcatheter aortic valve implantation
J Am Coll Cardiol
(2013)
R.K. Binder et al.
The impact of integration of a multidetector computed tomography annulus area sizing algorithm on outcomes of transcatheter aortic valve replacement: a prospective, multicenter, controlled trial
J Am Coll Cardiol
(2013)
E. Durand et al.
Transfemoral aortic valve replacement with the Edwards SAPIEN and Edwards SAPIEN XT prosthesis using exclusively local anesthesia and fluoroscopic guidance: feasibility and 30-day outcomes
JACC Cardiovasc Interv
(2012)
A.P. Kappetein et al.
Updated standardized endpoint definitions for transcatheter aortic valve implantation: Valve Academic Research Consortium-2 consensus document
J Am Coll Cardiol
(2012)
J. Webb et al.
Transcatheter aortic valve implantation: a Canadian Cardiovascular Society Position Statement
Can J Cardiol
(2012)
R.A. Nishimura et al.
2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol
(2014)
J.G. Webb et al.
Current status of transcatheter aortic valve replacement
J Am Coll Cardiol
(2012)
M.B. Leon et al.
Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery
N Engl J Med
(2010)

D.H. Adams et al.

Transcatheter aortic-valve replacement with a self-expanding prosthesis

N Engl J Med

(2014)

C.R. Smith et al.

Transcatheter versus surgical aortic-valve replacement in high-risk patients

N Engl J Med

(2011)

S. Lauck et al.

Implementation of processes of care to support transcatheter aortic valve replacement programs

Eur J Cardiovasc Nurs

(2013)

Cited by (29)

Comparison of Deep Sedation and General Anesthesia With an Endotracheal Tube for Transcaval Transcatheter Aortic Valve Replacement: A Pioneering Institution's Experience
2021, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Larger studies with a more substantial cohort of patients should examine if certain patient characteristics could predict the need for GA, but this may not be possible as TC-TAVR is a very uncommon procedure. Although not specific for DS, there is evidence that a multidisciplinary team and review of baseline patient characteristics can help with deciding on minimalist versus GA pathways.15 However, there also is evidence that baseline patient characteristics for patients undergoing TF-TAVR with the minimalist technique are not predictive of intraoperative morbidity, which likely applies to TC-TAVR as well.16
Transcaval transcatheter aortic valve replacement (TC-TAVR) is an alternative approach to transcatheter aortic valve replacement involving deployment of the bioprosthetic valve via a conduit created from the inferior vena cava to the descending aorta in patients for whom the traditional transfemoral approach is not feasible. By analyzing the largest known cohort of TC-TAVR patients, the authors wished to compare hospital length of stay and post-procedure outcomes between patients who underwent the procedure under deep sedation (DS) and patients who underwent general anesthesia with an endotracheal tube.
Retrospective, single-center study.
Henry Ford Hospital in Detroit, MI.
Patients undergoing TC-TAVR from 2015 to 2018.
Seventy-nine patients were included in the analysis, which consisted of 38 under general anesthesia with an endotracheal tube and 41 under DS. The sample was divided into a general anesthesia (GA) group and DS group. There were no significant differences in implant success rate or post-procedure outcomes, including in-hospital mortality (p = 0.999) and major vascular complication rate (p = 0.481), between the two groups. Patients in the GA group stayed a median of 24 hours longer in the intensive care unit (ICU) (p < 0.001) and one day longer in the hospital (p = 0.046) after the procedure compared to patients in the DS group. The median procedure time was significantly lower (135 minutes) in the DS group compared to the GA group (167 minutes, p < 0.001).
Patients undergoing TC-TAVR under DS had similar postoperative outcomes and shorter post-procedure hospital and ICU lengths of stay compared to general anesthesia. In the authors’ experience, DS is the preferred anesthetic technique for TC-TAVR.
Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP)
2021, Revista Espanola de Anestesiologia y Reanimacion
La vía clínica de recuperación intensificada en cirugía cardiaca (RICC) pretende identificar, difundir y favorecer la implementación de las mejores actuaciones basadas en la evidencia científica para disminuir la variabilidad en la práctica clínica. La puesta en marcha de estas prácticas en el proceso clínico global favorecerá la obtención de mejores resultados, acortamiento de estancias hospitalarias y en la Unidad de Cuidados Críticos, lo que permitirá una reducción de costes y una mayor eficiencia. Tras realizar una revisión sistemática en cada uno de los puntos del proceso perioperatorio en cirugía cardiaca, se han redactado recomendaciones basadas en la mejor evidencia científica disponible en la actualidad con el consenso de las sociedades científicas implicadas.
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP)
2021, Cirugia Cardiovascular
La vía clínica de recuperación intensificada en cirugía cardiaca (RICC) pretende identificar, difundir y favorecer la implementación de las mejores actuaciones basadas en la evidencia científica para disminuir la variabilidad en la práctica clínica. La puesta en marcha de estas prácticas en el proceso clínico global favorecerá la obtención de mejores resultados, acortamiento de estancias hospitalarias y en la Unidad de Cuidados Críticos, lo que permitirá una reducción de costes y una mayor eficiencia. Tras realizar una revisión sistemática en cada uno de los puntos del proceso perioperatorio en cirugía cardiaca, se han redactado recomendaciones basadas en la mejor evidencia científica disponible en la actualidad con el consenso de las sociedades científicas implicadas.
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
Discharge Location and Outcomes After Transcatheter Aortic Valve Implantation
2021, American Journal of Cardiology
The relation between discharge location and outcomes after transcatheter aortic valve implantation (TAVI) is largely unknown. Thus, the objective of this study was to investigate the impact of discharge location on clinical outcomes after TAVI. Between August 2007 and December 2018, consecutive patients who underwent transfemoral TAVI at Bern University Hospital were grouped according to discharge location. Clinical adverse events were adjudicated according to VARC-2 end point definitions. Of 1,902 eligible patients, 520 (27.3%) were discharged home, 945 (49.7%) were discharged to a rehabilitation clinic and 437 (23.0%) were transferred to another institution. Compared with patients discharged to a rehabilitation facility or another institution, patients discharged home were younger (80.8 ± 6.5 vs 82.9 ± 5.4 and 82.8 ± 6.4 years), less likely female (37.3% vs 59.7% and 54.2%), and at lower risk according to STS-PROM (4.5 ± 3.0% vs 5.5 ± 3.8% and 6.6 ± 4.4%). At 1 year follow-up, patients discharged home had similar rates of all-cause mortality (HR_adj 0.82; 95% CI 0.54 to 1.24), cerebrovascular events (HR_adj 1.04; 95% CI 0.52 to 2.08) and bleeding complications (HR_adj 0.93; 95% CI 0.61 to 1.41) compared with patients discharged to a rehabilitation facility. Patients discharged home or to rehabilitation were at lower risk for death (HR_adj 0.37; 95% CI 0.24 to 0.56 and HR_adj 0.44; 95% CI 0.32 to 0.60) and bleeding (HR_adj 0.48; 95% CI 0.30 to 0.76 and HR_adj 0.66; 95% CI 0.45 to 0.96) during the first year after hospital discharge compared with patients transferred to another institution. In conclusion, discharge location is associated with outcomes after TAVI with patients discharged home or to a rehabilitation facility having better clinical outcomes than patients transferred to another institution.
Clinical Trial Registration: https://www.clinicaltrials.gov. NCT01368250.
Restructuring Structural Heart Disease Practice During the COVID-19 Pandemic: JACC Review Topic of the Week
2020, Journal of the American College of Cardiology
Citation Excerpt :
Use of high-flow nasal cannula and noninvasive positive pressure ventilation should be avoided, as they are associated with increased generation of infectious aerosols. TAVR should be performed with a modified minimalist approach, including use of conscious sedation, avoidance of transesophageal echocardiography, and specific plans to minimize the length of stay in the hospital (21,22). Every effort should be undertaken to ensure a safe, expedited recovery and discharge to home (Figure 4).
Patients with structural heart disease are at increased risk of adverse outcomes from the coronavirus disease-2019 (COVID-19) due to advanced age and comorbidity. In the midst of a global pandemic of a novel infectious disease, reality-based considerations comprise an important starting point for formulating clinical management pathways. The aims of these “crisis-driven” recommendations are: 1) to ensure appropriate and timely treatment of structural heart disease patients; 2) to minimize the risk of COVID-19 exposure to patients and health care workers; and 3) to limit resource utilization under conditions of constraint. Although the degree of disruption to usual practice will vary across the United States and elsewhere, we hope that early experiences from a heart team operating in the current global epicenter of COVID-19 may prove useful for others adapting their practice in advance of local surges of COVID-19.
Minimalist Transcatheter Aortic Valve Replacement: The Right Pathway Forward?
2018, Interventional Cardiology Clinics
Citation Excerpt :
An example is the Vancouver Clinical Pathway, which is focused on next-day discharge, with standardized preprocedural, periprocedural, and postprocedural management guidelines (Fig. 1). The aims of the Vancouver Clinical Pathway are to (1) implement risk-stratified periprocedural minimalist practices, (2) use a standardized approach to postprocedure care after transfemoral TAVR, (3) identify patients suitable for early discharge, and (4) reduce overall length of stay (LOS).14,15 This approach was assessed in the Multidisciplinary, Multimodality, but Minimalist (3M) TAVR Study.

View all citing articles on Scopus

: See page 1586 for disclosure information.

View full text

Clinical ResearchRisk Stratification and Clinical Pathways to Optimize Length of Stay After Transcatheter Aortic Valve Replacement

Abstract

Background

Methods

Results

Conclusions

Résumé

Introduction

Méthodes

Résultats

Conclusions

Section snippets

Standardized screening

Results

Discussion

Disclosures

Prog Cardiovasc Dis

Prog Cardiovasc Dis

J Am Coll Cardiol

J Am Coll Cardiol

JACC Cardiovasc Interv

J Am Coll Cardiol

Can J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery

N Engl J Med

Transcatheter aortic-valve replacement with a self-expanding prosthesis

N Engl J Med

Transcatheter versus surgical aortic-valve replacement in high-risk patients

N Engl J Med

Implementation of processes of care to support transcatheter aortic valve replacement programs

Eur J Cardiovasc Nurs

Clinical Research
Risk Stratification and Clinical Pathways to Optimize Length of Stay After Transcatheter Aortic Valve Replacement