Delayed discharge after TAVR growing less common, tied to worse outcomes

Patients who remain in the hospital for longer than three days following transcatheter aortic valve replacement (TAVR) are at a 45 percent increased risk of death within one year versus those discharged sooner after the procedure, according to an analysis of the Transcatheter Valve Therapy registry published in JACC: Cardiovascular Interventions.

Lead author Siddharth A. Wayangankar, MD, with the department of medicine at the University of Florida, and colleagues studied nearly 25,000 patients who underwent TAVR from 2011 at 2015. Fifty-five percent of patients were discharged within 72 hours, while the rest were classified as the delayed discharge group.

Notably, from the beginning to the end of the study, the proportion of people who experienced delayed discharge declined from 62 percent to 34 percent. According to the researchers, improvements in TAVR devices and techniques, operator experience and the increased adoption of the minimalist approach—in which patients are under local anesthesia and a post-procedural ICU stay is avoided—have all contributed to shorter lengths of stay.

Shorter stays have previously been linked to equivalent or better outcomes and lower costs. In this study, delayed discharge was tied to a 45 percent increased risk of all-cause mortality after adjusting for in-hospital complications.

“This result is remarkable, and although I think that residual confounding in terms of patients' risk profile could have affected this finding, it further reinforces the assumption of the safety of early discharge after transfemoral TAVR,” Marco Barbanti, MD, with the University of Catania in Italy, wrote in a related editorial.

There were several characteristics independently associated with requiring a hospital stay longer than 72 hours, including age older than 85, black or Hispanic race, a prior mitral valve procedure, diabetes or severe symptomatic heart failure.

“These predictors (of delayed and early discharge) could be used to develop risk scores that could be used by clinicians for appropriate patient selection and use of resources by administrators, insurance companies, and policymakers to formulate stratified bundle payments for TAVR procedures in future,” Wayangankar and co-authors wrote.

Barbanti said the study suggests “a minimalistic approach to TAVR is already routine and has been shown to be as safe and effective as the more traditional approach.” However, he cautioned against overusing the minimalistic strategy and prioritizing a short length of stay in all cases.

“I firmly believe that ‘timely’ discharge, rather than ‘early’ discharge, should be the main objective of our practice,” he wrote. “As physicians and academics, we have the duty to ensure that the pursuit of a minimalist approach in TAVR does not take the drift of a simplistic strategy that could compromise the quality and the effectiveness of our care.”