Is Same-Day Discharge Post-TAVR Safe, Feasible in ‘Carefully Selected’ Patients?

Same-day discharge following transfemoral TAVR may be safe and feasible with careful patient selection, according to two studies published in JACC: Cardiovascular Interventions.

In the first study, which will be presented April 4 at ACC.22, Amar Krishnaswamy, MD, FACC, et al., evaluated the feasibility and safety of same-day discharge after transfemoral TAVR during the COVID-19 pandemic by comparing in-hospital and 30-day events among patients discharged on the same day vs. the following day. Candidates for same-day discharge met criteria: use of conscious sedation for the procedure, six hours of bedrest with rhythm monitoring post-TAVR, absence of major complications or need for further observation, stability of hemodynamics and ECG during recovery, comfortable ambulation post-procedure, and presence of post-discharge social support. After the six-hour recovery period, the operating physician and bedside nursing team determined whether the patient met criteria for discharge.

The cohort consisted of 1,315 patients ages 18 years and older who received transfemoral TAVR from January 2019 to November 2020 at a single TAVR center. Among all patients, 1,113 were discharged on the day of the procedure (597 in 2019 and 516 in 2020). Of 516 transfemoral TAVR patients in 2020, 114 patients (22.1%) were discharged the same day vs. 329 patients (63.8%) on the next day. There were no deaths among those with a same-day discharge vs. three deaths in those discharged the next day. New-onset left bundle branch block (LBBB) occurred in 5.3% of those discharged the same day, compared with 11.9% of those discharged the next day. The 30-day readmission rate was 6.1% in those discharged the same day vs. 7% in those discharged the next day.

According to the researchers, the study demonstrates that same-day discharge after transfemoral TAVR is safe in "carefully selected" patients who do not have post-procedural complications or experience post-TAVR conduction disease. Same-day discharge may provide "benefits in optimizing limited health care resource utilization … and minimizing infectious exposure of patients to life-threatening viruses," they add, concluding that large, multicenter studies that confirm the findings "will be beneficial" and "[may] make [same-day discharge] more widely acceptable in routine clinical practice."

Meanwhile, in the Multicenter PROTECT TAVR Study, Madeleine Barker, MD, et al., evaluated the safety and feasibility of same-day discharge after transfemoral TAVR at seven international sites from March 2020 to August 2021 during the COVID-19 pandemic. During the study period, 2,100 patients received transfemoral TAVR. Of these, 124 patients (5.9%) completed the procedure before noon and were selected for same-day discharge. Patients discharged the same day were age 78.9 years on average, and 29% were women and 32.3% had preexisting permanent pacemakers (PPMs).

Results showed no major vascular complications, strokes or death during the index admission, although one patient discharged the same day required PPM implantation for post-TAVR complete heart block. The composite outcome of cardiovascular death, stroke, myocardial infarction, all-cause readmission, major vascular complications, and new PPM implantation occurred in 106 patients (5.7%). There were no cardiovascular deaths at 30 days. The rates of 30-day all-cause and cardiovascular readmission were 5.7% (6 patients) and 2.8% (3 patients), respectively.

According to the authors, the research is the first multicenter study to demonstrate the "safety of [same-day discharge] post-TAVR in highly selected patients at low risk for postoperative conduction disease and vascular complications." They conclude that same-day discharge "may have a potential role in highly selected patients even when the COVID-19 pandemic abates."

The hospital bed and resource shortages associated with the COVID-19 pandemic "created the perfect environment for a concept that would have seemed outlandish only a few short years ago: [same-day discharge] post-TAVR," write Jay Giri, MD, MPH, and Paul N. Fiorilli, MD, FACC, in an accompanying editorial comment. They add that both studies "provide an initial evidence base for expedited post-TAVR discharge" and "lay a roadmap for the broader implementation of [a same-day discharge] strategy after TAVR."

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, EP Basic Science, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Interventions and Structural Heart Disease, Exercise

Keywords: ACC Annual Scientific Session, ACC22, Adolescent, Patient Discharge, COVID-19, Transcatheter Aortic Valve Replacement, Patient Readmission, Feasibility Studies, Aftercare, Bed Rest, Bundle-Branch Block, Conscious Sedation, Pandemics, Patient Selection, Myocardial Infarction, Social Support, Hemodynamics, Delivery of Health Care, Walking, Pacemaker, Artificial, Physicians, Hospitals, Stroke, Electrocardiography, SARS-CoV-2, Aortic Valve Stenosis, Aortic Valve

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