Early discharge after TAVR appears safe, feasible with Sapien XT

Early discharge of patients who underwent transcatheter aortic valve replacement (TAVR) using a Sapien XT valve was safe and feasible, according to a single-center study. The hospital has managed to cut the mean length of stay in transfemoral cases by almost half.

Eric Durand, MD, PhD, and researchers at Hospital Charles Nicolle in Rouen, France, have been advocating a minimalist approach to TAVR procedures in patients with severe aortic stenosis when conditions allow. Those conditions include a transfemoral procedure, local anesthesia, transesophageal echocardiography and the use of lower profile TAVR devices. Edwards Lifesciences’ Sapien XT with an 18-French delivery system became commercially available in Europe in 2010 and was approved in the U.S. with a 16-French sheath in 2014.

Durand et al retrospectively assessed 337 patients who received a Sapien XT valve during a transfemoral TAVR procedure between 2009 and 2013. The care team monitored all patients for at least 24 hours in the intensive care unit, conducted daily electrocardiography tests until discharge and evaluated patients by transthoracic echocardiography before discharge. Their primary endpoint was the combination of death and rehospitalization at 30 days after discharge.

They divided patients into two groups: early discharge of three days or less (36 percent of the patients) or late discharge of more than three days (64 percent). Patients in the early discharge group were less likely to be symptomatic, have renal failure or have a history of atrial fibrillation. They were also more likely to have a pacemaker.

Having a pre-existing pacemaker and no acute kidney injury emerged as independent predictors of early discharge while previous balloon aortic valvuloplasty and blood transfusions after TAVR were independent predictors of late discharge.

Between 2009 and 2013, the proportion of early discharge cases grew from zero to 53.2 percent and the mean length of stay dropped from 9.6 days to 5.0 days. At 30-day follow-up, 3.3 percent of the early discharge group experienced the primary endpoint vs. 5.1 percent in the late discharge group.

“Using a step-by-step simplification of transfemoral [TAVR] procedures, early discharge has emerged in our group as a reasonable option considering the reduction of required sheath size, a careful selection of patients avoiding compassionate cases, and the growing experience of the operators,” Durand et al wrote. They added that the approach also may be cost-effective, based on other research on a minimalist TAVR approach that found cost savings.

Their hospital is a high-volume TAVR center with experienced physicians. They recommended conducting a prospective safety and feasibility study to confirm their results. The study was published in the April 15 issue of the Journal of the American College of Cardiology.