Study Explores Safety of Early Discharge After Transfemoral TAVR
Many patients who undergo transfemoral TAVR may be safely discharged home within 72 hours without compromising outcomes, according to a study published online June 19, 2015, ahead of print in Heart.
The study was motivated by a “desire to accelerate patients’ recovery and mobilization after the procedure and to minimize unnecessary use of medical resources,” write Marco Barbanti, MD, of Ferrarotto Hospital (Catania, Italy), and colleagues. “Postprocedural [length of stay] is one of the main factors contributing to the increase in periprocedural costs of [TAVR].”
The investigators compared outcomes for high-risk or inoperable patients (average age about 80 years; approximately 55% women) who underwent transfemoral TAVR at their institution between June 2007 and July 2014 and were discharged home either within 72 hours (n = 107) or after 3 days (n = 358).
Devices used were predominantly Sapien and Sapien XT (Edwards Lifesciences; n = 127) and CoreValve (Medtronic; n = 331).
Patients in the early-discharge group were slightly younger, more likely to be men, and had higher rates of prior permanent pacemaker, while those in the late-discharge group had higher rates of prior balloon aortic valvuloplasty and NYHA class IV heart failure.
Early Discharge Safe, Increasing
The mean length of stay was 2.2 days in the early-discharge group and 6.5 days in the late-discharge group (P < .001). Among the early discharges, 28.9% left the hospital within 24 hours, 30.5% within 48 hours, and 43.8% within 72 hours.
Device success was similar between the groups, as were rates of bailout valve-in-valve implantation, valve embolization, and more-than-mild paravalvular regurgitation.
In multivariable regression analysis, NYHA class IV heart failure and any bleeding were associated with a lower likelihood of early discharge, while the presence of a permanent pacemaker before TAVR and a more recent year of procedure predicted early discharge (table 1).
When the study period was divided into 2-year increments, a sharp increase was seen in the proportion of patients discharged early after TAVR in later years—from 5.6% in 2007-2008 to 50.5% in 2013-2014. The likelihood of early discharge did not vary by valve type.
Propensity matching confirmed that compared with those discharged later, patients discharged early had lower rates of in-hospital bleeding (7.9% vs 19.4%; P = .014), major vascular complications (2.3% vs 9.1%; P = .038) and new pacemaker implantation (7.9% vs 18.5%; P = .021). However, there was no difference in 30-day rates of the composite safety endpoint of death, permanent pacemaker implantation, bleeding, and rehospitalization for any cause or any of its components (table 2).
Emphasis on Safety Before Cost
Dr. Barbanti and colleagues say that the study is in line with others that have demonstrated the safety of early discharge after TAVR. They add that current evidence supports the assertion that reducing length of stay may help rein in the high costs of TAVR.
“However, the objective of saving resources has to be achieved without compromising the safety of the procedure in order for a strategy of early discharge to be termed ‘economically attractive,’” they write. “Therefore, the aim is to intervene on those cases of prolonged hospitalization without a real clinical reason.”
As for the escalating use of early discharge in recent years, Dr. Barbanti and colleagues say that experience in postprocedural management, changing risk profiles, and teaching programs aimed at a wide range of hospital staff may be responsible for the shift.
The study authors add it is reasonable to assume that as the indications for TAVR expand into lower-risk populations and complication rates fall, this strategy may be adopted more frequently in the future.
Barbanti M, Capranzano P, Ohno Y, et al. Early discharge after transfemoral transcatheter aortic valve implantation. Heart. 2015;Epub ahead of print.
- Dr. Barbanti reports no relevant conflicts of interest.
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