Early Versus Standard Discharge After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Rafail A Kotronias; Michael Teitelbaum; John G Webb; Darren Mylotte; Marco Barbanti; David A Wood; Brennan Ballantyne; Alyson Osborne; Karla Solo; Chun Shing Kwok; Mamas A Mamas; Rodrigo Bagur

doi:10.1016/j.jcin.2018.04.042

Early Versus Standard Discharge After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

JACC Cardiovasc Interv. 2018 Sep 10;11(17):1759-1771. doi: 10.1016/j.jcin.2018.04.042.

Authors

Affiliations

¹ Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom; Oxford University Clinical Academic Graduate School, Oxford University, Oxford, United Kingdom.
² London Health Sciences Centre, London, Ontario, Canada.
³ Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
⁴ Galway University Hospitals, National University of Ireland, Galway, Ireland.
⁵ Division of Cardiology, Cardio-Thoracic-Vascular Department, University of Catania, Catania, Italy.
⁶ Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
⁷ Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom; The Heart Centre, Royal Stoke Hospital, University Hospital of North Midlands Trust, Stoke-on-Trent, United Kingdom.
⁸ Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom; London Health Sciences Centre, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada. Electronic address: [email protected].

PMID: 30190065
DOI: 10.1016/j.jcin.2018.04.042

Abstract

Objectives: This study sought to assess the clinical outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) with early discharge (ED) versus standard discharge (SD) pathways.

Background: Minimalist approaches for TAVR have been developed targeting different aspects of the procedure such as local anesthesia or sedation, intraprocedural imaging, vascular access, post-operative monitoring and care, and discharge planning. Their incorporation into routine clinical practice aims to reduce length of hospital stay and health care cost utilization without adversely affecting outcomes when compared with standard approaches.

Methods: The authors conducted a search of MEDLINE and EMBASE to identify studies that investigated ED (≤3 days) versus SD in TAVR patients. Random-effects meta-analyses were used to estimate the effect of ED compared with SD with regard to 30-day mortality after discharge, 30-day readmission rate, and need for permanent pacemaker implantation (PPI) following discharge.

Results: Eight studies including 1,775 participants (ED, n = 642) fulfilled the inclusion criteria. The mean age was 82.4 years and STS score was 6.7. Meta-analyses evaluating discharge to 30-day mortality (odds ratio [OR]: 0.65; 95% confidence interval [CI]: 0.23 to 1.82; I² = 0%) and discharge to 30-day new PPI (OR: 1.61; 95% CI: 0.19 to 13.71; I² = 40%) showed no significant difference in an ED compared with a SD strategy. Notably, ED patients were less likely to be readmitted after ED when compared with SD patients (OR: 0.63; 95% CI: 0.41 to 0.98; p = 0.04, I² = 0%).

Conclusions: ED following uncomplicated TAVR is safe in terms of discharge to 30-day mortality or need for PPI following discharge. Moreover, ED patients experienced a lower rate of readmissions. These data support the safety of programs aiming an ED pathway in selected TAVR patients. Institutional protocols with the input from different members of the multidisciplinary heart team should be devised to optimize discharge processes to improve health care resource utilization.

Keywords: TAVR; aortic stenosis; early discharge; readmission; transcatheter.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Systematic Review

MeSH terms

Aged
Aged, 80 and over
Female
Humans
Length of Stay*
Male
Patient Discharge*
Patient Readmission
Patient Safety
Risk Assessment
Risk Factors
Time Factors
Transcatheter Aortic Valve Replacement* / adverse effects
Transcatheter Aortic Valve Replacement* / mortality
Treatment Outcome