Same-day Discharge: Taking Pause over TAVR’s Milestone

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TAVR-Piedmont.jpg - TAVR at Piedmont Heart Institute
From left, Vivek Rajagopal, MD, Christopher Meduri, MD, and James Kauten, MD, perform a transcatheter aortic valve replacement (TAVR) on a patient at Piedmont Heart Institute in Atlanta. Piedmont has reduced its TAVR length of stay by four days within one year for a cost savings of $6,000 per case.
Source: Piedmont Heart Institute

One morning last year, a patient checked into a hospital in Canada as the first transcatheter aortic valve replacement (TAVR) case of the day. That evening he checked out, an eyebrow-raising feat for a procedure that typically requires several days of hospitalization. While same-day discharge TAVR can be done, should it? For clinical and financial reasons, proceed with caution.

Pieces fall together

François Sévigny was not your typical TAVR patient. At 65 years old, he qualified for TAVR on technical grounds: His severe aortic stenosis was considered inoperable because radiation therapy had left him with a hostile chest. He was otherwise active and functional. He had been instructed that his visit might be short, perhaps allowing him to leave the hospital by the next day. He had family to stay with him at home, which was close to the hospital.

The transfemoral procedure, the first of the day for Philippe Généreux, MD, and the rest of the heart team at Hospital of the Sacred Heart in Montreal, went without a hitch. They used conscious sedation, implanted a Sapien XT device (Edwards Lifesciences) and ascertained complete hemostasis on angiogram, all within a procedural time of 37 minutes.

When Généreux stopped by after his second TAVR case, he found the patient sitting in a chair, eating lunch. “He asked me, ‘Can I go home tonight?’ joking a little bit.” Généreux responded that if Sévigny was walking within six hours of the procedure, they could revisit the idea.

“During the third case I started thinking about this as a real possibility,” Généreux recalls. With the concurrence of the heart team, he approved the same-day discharge, requesting that Sévigny remain through dinner, just for reassurance. “I didn’t plan to do it upfront,” Généreux says. “It was purely coincidental that the patient was the first in the morning, a perfect procedure with no complication at all in a perfect patient.”

In a report on the case, Généreux and his colleagues emphasized that the patient was carefully selected and discharged after meeting numerous procedural and patient-level criteria and had no adverse events at his 30-day follow-up (Catheter Cardiovasc Interv online July 21, 2015). Reactions to the report ranged from astonishment to admonishment, he says, with some questioning the benefit over an overnight stay.  

“OK, we know we can do it, but should we really do it?” he says. “The goal is to identify patients who would be able to go home safely and not come back except for their regular follow-up.”

Less is more

As TAVR devices and techniques have improved, so has an appreciation for care before and after the procedure. Besides selecting those patients most likely to benefit from TAVR, some programs strive to identify appropriate candidates for early discharge. To do so, they have expanded the concept of the heart team to include “the role of nurses, the role of geriatricians, the roles of people who understand that success is not when the valve goes in but when the patient goes home within an optimal length of stay,” says Sandra Lauck, PhD, RN, a clinical nurse specialist at St. Paul’s Hospital in Vancouver.

Lauck, and St. Paul’s colleagues David Wood, MD, and John Webb, MD, are conducting the Multidisciplinary, Multimodality but Minimalist (3M) TAVR study to evaluate the feasibility, safety and efficacy of next-day discharge using a clinical pathway to screen and manage TAVR patients. In addition to physicians’ assessment of a patient’s anatomical suitability, nurses evaluate his or her physical, mental and social function to form an individualized plan. Généreux, a 3M collaborator, consulted their discharge criteria in Sévigny’s case.

The approach tries to maximize patients’ reserve—how much gas they have in the tank going into a TAVR procedure—and minimize the stressors that can destabilize them during the admission. “We have understood that hospitals can be kind of danger zones for TAVR patients,” Lauck says. The prevailing wisdom may favor longer bed rest, but that also may put them at risk of deconditioning and other complications.

“Resting the elderly patient is not doing good,” she notes. “They need a fairly active clinical pathway to resume their baseline. The sooner they get back to baseline, the better their outcome will be.”

3M is beginning to show positive results. Danny Dvir, MD, an interventional cardiologist at St. Paul’s and a 3M researcher, reported at TCT.15 that in recent months 64 of 66 patients prospectively enrolled