Next-Day Discharge After Minimalist TAVR

Study Questions:

What are the predictors and the safety of next-day discharge (NDD) after transcatheter aortic valve replacement (TAVR)?

Methods:

The investigators reviewed 663 consecutive patients who underwent elective balloon-expandable TAVR (from July 2014 to July 2016) at their institution. The authors first determined predictors of NDD in patients who underwent minimalist transfemoral TAVR. After excluding cases with complications, they compared 30-day and 1-year outcomes between NDD patients and those with longer hospital stay using Cox regression, adjusting for the Society of Thoracic Surgeons Predicted Risk of Mortality. The primary endpoint was the composite of mortality and readmission at 1 year. To determine predictors of NDD, single-predictor logistic regression models were fit to assess the association of each individual predictor with NDD.

Results:

A total of 150 patients had NDD after TAVR and 210 patients had non-NDD. Mean age and the Society of Thoracic Surgeons Predicted Risk of Mortality were 80.7 ± 8.8 years and 6.6 ± 3.7%, respectively. Predictors of NDD were male sex (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.28-3.18), absence of atrial fibrillation (OR, 1.62; 95% CI, 1.02-2.57), serum creatinine (OR, 0.71; 95% CI, 0.55-0.92), and age (OR, 0.95; 95% CI, 0.93-0.98). As expected, 84% of patients with complications had non-NDD. After excluding cases with complications, there was no difference in hazard rates of the 30-day composite outcome between NDD and non-NDD (hazard ratio, 0.62; 95% CI, 0.20-1.91), but the hazard of the composite outcome at 1 year was significantly lower in the NDD group (hazard ratio, 0.47; 95% CI, 0.27-0.81). This difference in the composite outcome can be explained by the lower hazard of noncardiovascular-related readmission in the NDD group.

Conclusions:

The authors concluded that factors predicting next-day discharge include male sex, absence of atrial fibrillation, lower serum creatinine, and younger age.

Perspective:

This study reports that predictors of next-day discharge were male sex, absence of atrial fibrillation, lower serum creatinine, and younger age and that among patients without complications in the first 24 hours post-procedure, there was no difference in mortality at 30 days and better composite outcomes for next-day discharge patients at 1 year. These data suggest that next-day discharge in patients without in-hospital complications may be appropriate after transfemoral balloon-expandable TAVR. Additional prospective studies are indicated to validate these findings.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Atrial Fibrillation, Cardiac Surgical Procedures, Creatinine, Geriatrics, Heart Valve Diseases, Length of Stay, Outcome Assessment (Health Care), Patient Discharge, Patient Readmission, Transcatheter Aortic Valve Replacement


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