Researchers ID predictors of next-day discharge after ‘minimalist’ TAVR

Next-day discharge after minimalist transcatheter aortic valve replacement (TAVR) was safe for patients who didn’t experience perioperative complications and was linked to better one-year outcomes versus patients discharged later, according to a single-center study published in JACC: Cardiovascular Interventions.

Lead researcher Norihiko Kamioka, MD, with the Emory University School of Medicine, and colleagues analyzed 150 patients with next-day discharge (NDD) and 210 with later discharges. All individuals underwent transfemoral TAVR using the minimalist approach of conscious sedation and local anesthesia, which has been demonstrated to make early discharge more feasible. Two balloon-expandable valves manufactured by Edwards Lifesciences—the Sapien XT and the Sapien 3—were used in the study.

Kamioka et al. found men were twice as likely to be discharged the day after their operation than women. Other predictors of NDD were the absence of atrial fibrillation (62 percent increased odds of NDD), low serum creatinine levels (29 percent) and age (5 percent less chance of NDD with each additional year).

“We found male sex was the strongest positive predictor of NDD,” the authors wrote. “Previous reports have shown that male sex is associated with fewer vascular complications and bleeding after TAVR than is female sex due to anatomic differences, leading to a slightly longer hospital stay for women. However, female sex has been previously reported to be associated with better short- and midterm outcomes after TAVR in older-generation devices. The presence of the sex disparity in our study is intriguing and stresses the need for further examination of sex differences among TAVR patients using current-generation devices.”

Kamioka and colleagues said it wasn’t surprising higher serum creatinine was a negative predictor of NDD considering patients with kidney dysfunction may require additional in-hospital treatment before discharge. Likewise, additional challenges with managing atrial fibrillation—such as the need for anticoagulants and monitoring variable heart rates—could have led to longer hospitalizations for those patients following TAVR.

After excluding patients who experienced complications in the first 24 hours after TAVR, the researchers evaluated whether NDD was associated with lower rehospitalizations and mortality over two timeframes—30 days and one year. There was no significant difference in the composite endpoint at 30 days, but NDD patients showed a 53 percent decreased risk of rehospitalization or death at one year.

However, Kamioka et al. attributed that to better baseline health, noting the difference in rehospitalizations was driven by noncardiovascular causes.

Still, they said “a strategy of NDD in patients without in-hospital complications may be appropriate after transfemoral balloon-expandable TAVR,” though they urged additional studies to validate their findings.

In an accompanying editorial, Molly Szerlip, MD, questioned whether the study added any new information to the field. Patients who had a general anesthetic, a complication, received a self-expanding valve or did not undergo preprocedural 3D multidetector CT were excluded from the study, limiting its generalizability to a general TAVR population. In addition, the characteristics that were predictive of NDD are already included in the Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) score.

“It is therefore of no surprise that these 4 variables have the same receiver-operating characteristic as the STS PROM,” wrote Szerlip, with the Heart Hospital Baylor Plano in Texas. “It is not clear as to how these predictors from the study add to the STS PROM in predicting who is more likely to go home the next day.”

Szerlip said clinicians should “minimize the interventions for each patient” at every step of care. For TAVR, this can mean performing the procedure without pulmonary artery catheters, urinary catheters or narcotics. Also, physicians should urge mobilization within four hours of the procedure if possible.

“Each institution should institute its own care pathway including many or most of the components suggested ... and not necessarily try to figure out a priori which patients based on baseline characteristics should receive NDD,” she wrote. “They should instead minimalize the amount of unnecessary care for every patient and as a result their length of stay will decrease and rate of NDD will increase.”