Vancouver 3M Clinical Pathway for TAVR

Study Questions:

What is the safety and efficacy of next-day discharge using the Vancouver 3M (Multidisciplinary, Multimodality, but Minimalist) Clinical Pathway after transfemoral transcatheter aortic valve replacement (TAVR)?

Methods:

The investigators enrolled patients from six low-volume (<100 TAVR/year), four medium-volume, and three high-volume (>200 TAVR/year) centers in Canada and the United States. The primary outcomes were a composite of all-cause death or stroke by 30 days and the proportion of patients successfully discharged home the day following TAVR. Rates of 30-day outcomes are reported using Kaplan-Meier estimates to account for deaths, lost to follow-up, whereas rates of next-day discharge and periprocedural events are reported as crude rates, and 95% confidence intervals are given for all outcomes.

Results:

Of 1,400 screened patients, 411 were enrolled at 13 centers and received a SAPIEN XT (58.2%) or SAPIEN 3 (41.8%) valve (Edwards Lifesciences, Irvine, CA). In centers enrolling exclusively in the study, 55% of screened patients were enrolled. The median age was 84 years (interquartile range [IQR], 78-87 years) with a median Society of Thoracic Surgeons (STS) score of 4.9% (IQR, 3.3-6.8%). Next-day discharge home was achieved in 80.1% of patients, and within 48 hours in 89.5%. The composite of all-cause mortality or stroke by 30 days occurred in 2.9% (95% confidence interval, 1.7-5.1%), with neither component of the primary outcome affected by hospital TAVR volume (p = 0.51). Secondary outcomes at 30 days included major vascular complication 2.4% (n = 10), readmission 9.2% (n = 36), cardiac readmission 5.7% (n = 22), new permanent pacemaker 5.7% (n = 23), and > mild paravalvular regurgitation 3.8% (n = 15).

Conclusions:

The authors concluded that adherence to the Vancouver 3M Clinical Pathway at low-, medium-, and high-volume TAVR centers allows next-day discharge home with excellent safety and efficacy outcomes.

Perspective:

This study reports that among patients undergoing contemporary balloon-expandable transfemoral TAVR at low-, medium-, and high-volume centers, adherence to the Vancouver 3M Clinical Pathway allows next-day discharge home without compromising clinical or hemodynamic outcomes. Additional studies with longer-term follow-up are indicated to confirm these findings and determine the potential cost savings and improvements in quality of life to be derived by adopting this minimalist clinical pathway as the new benchmark.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Aortic Valve Insufficiency, Critical Pathways, Heart Valve Diseases, Heart Valve Prosthesis, Geriatrics, Outcome Assessment (Health Care), Pacemaker, Artificial, Patient Discharge, Patient Readmission, Secondary Prevention, Stroke, Transcatheter Aortic Valve Replacement


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