Centers may be able to trim thousands of dollars off the cost of a transfemoral transcatheter aortic valve replacement (TAVR) procedure without compromising care using a minimalist approach, according to a recently published study. Only experienced facilities should adopt this strategy, though, the lead author told Cardiovascular Business.
With the minimalist approach, physicians can perform elective transfemoral TAVRs in a cardiac catheterization laboratory rather than a hybrid operating room. The procedure requires local anesthesia rather than general anesthesia, percutaneous access and closure, minimal conscious sedation and transthoracic echocardiography.
“This strategy of [treating patients] awake in the cath lab saves money because we are doing everything with the least amount of resources,” said Vasilis Babaliaros, MD, co-director of the Structural Heart and Valve Center at Emory University Hospitals in Atlanta.
In a paper published in the July 29 issue of the Journal of the American College of Cardiology: Cardiovascular Interventions, Babaliaros and colleagues compared costs and outcomes for patients who underwent elective transfemoral TAVRs at their center between November 2010 and September 2013. The center initiated a minimalist approach for transfemoral TAVRs in May 2012 and now uses the approach in about 95 percent of its transfemoral TAVR cases.
Babaliaros et al treated 70 patients using the minimalist approach and 72 under the standard approach. All patients had severe aortic stenosis and were either inoperable or high-risk. Two patients who were not suitable for the minimalist approach because of obesity, an inability to lie flat for the duration of the procedure or breathing difficulties were placed in the standard approach group. All patients received the Sapien valve (Edwards Lifesciences).
The two patient groups had similar baseline characteristics and comorbidities. They achieved 100 percent procedural success in the minimalist group and 96 percent in the standard group. No patients died during the procedure in the minimalist group and three patients died in the standard group. Thirty-day mortality rates were similar for both groups and survival rates past one year were also similar.
The 30-day stroke and transient ischemic attack rate was 4.3 percent in the minimalist group vs. 1.4 percent in the standard group. Moderate or severe paravalvular leak was 3 percent vs. 5.8 percent, respectively.
Procedure room time, total intensive care unit length of stay and hospital length of stay were shorter under the minimal approach, at 56 minutes vs. 150 minutes, 22 hours vs. 28 hours and three days vs. five days, respectively. Hospital costs with the minimalist approach totaled $45,485 vs. $55,377 with the standard approach.
They calculated that the minimalist approach could achieve even greater cost savings with the introduction of lower-profile devices, which will broaden the pool of appropriate candidates for transfemoral TAVR.
Babaliaros cautioned that experience is critical before transitioning to the minimalist approach. “Using this strategy we’ve had good outcomes, good safety short term and long term, and cost savings,” he said. Centers that have overcome the learning curve, are comfortable with transfemoral TAVR, adept with percutaneous access and closure and patient selection “should consider moving onto a minimalist approach. We are not advocating this as a strategy for a center that just started.”