Next-day discharge (NDD) after transcatheter aortic valve replacement (TAVR) has gained significant momentum in recent years, helping care teams lower healthcare costs without increasing the risk of complications.
However, questions still remain about NDD after TAVR. Do self-expanding valves impact outcomes? Which patients are the best candidates for this strategy?
To answer these questions, and many more, a team of researchers explored data from nearly 30,000 TAVR patients, sharing its findings in the Journal of the American Heart Association.[1]
“Discharging patients too early from the hospital after TAVR could potentially lead to higher rates of readmission from heart failure, procedural complications, or late conduction disorders requiring permanent pacemaker (PPM) implantation,” wrote first author Wayne B. Batchelor, MD, MHS, an interventional cardiologist with the Inova Heart and Vascular Institute in Virginia, and colleagues. “Although feasibility and safety of NDD have been reported, prior studies have focused on balloon‐expandable rather than self‐expanding TAVR prostheses or have been statistically underpowered, lacked adjustment for confounders, limited in duration of follow‐up or not reflective of present‐day practice.”
Batchelor et al. focused on data from 29,597 patients treated with elective TAVR from July 2019 to June 2021 at one of 614 locations. All procedures were “initially uncomplicated.” Each patient received an Evolut R, Evolut PRO or Evolut PRO+ self-expanding TAVR valve manufactured by Medtronic. Data were taken from the Society of Thoracic Surgeons (STS) /American College of Cardiology Transcatheter Valve Therapy Registry.
These are four key takeaways from the group’s analysis:
1. Next-day discharge after TAVR with a self-expanding valve is gaining popularity
Overall, more than half (56%) of patients included in team’s analysis were treated with a NDD strategy. The NDD rate increased from 45.4% at the start of the study to 62.1% at the end, and the median length of stay decreased from two days to one.
Why has it gained popularity so quickly? The authors discussed a few possible explanations. More interventional cardiologists are embracing a “minimalist” approach to TAVR, for example, and the number of low-risk patients being considered for TAVR has increased over time.
The mean patient ages were 78.6 years old among NDD patients and 79.6 years old among non-NDD patients. NDD was more likely among low-risk patients (26.1% vs. 19%) and less likely among high-risk patients (37.4% vs. 44.5%). The NDD rates among intermediate-risk patients, meanwhile, were nearly identical.
2. After propensity score matching, next-day discharge patients were linked to improved patient outcomes
Propensity score matching was used to create two groups of 10,549 patients with comparable characteristics—one NDD group and one non-NDD group. Overall, the study’s primary endpoint—30-day readmission—was seen in 6.3% of NDD patients and 8.4% of non-NDD patients. The 30-day rates of all-cause death, stroke, major bleeding events and new permanent pacemaker (PPM) implantation were all also lower among NDD patients. In addition, one-year rates of all-cause death, major bleeding events and new PPM implantation were lower among NDD patients.
3. Specific patient variables were independently associated with lower and higher odds of being discharged the very next day after TAVR
Baseline conduction defects, higher STS risk scores, albumin <3.3 g/dL, new pathological Q-wave or left bundle branch block, the use of general anesthesia, longer procedure times and slower walking speeds/the inability to walk were all associated with lower odds NDD being the chosen strategy for that patient. Preexisting PPMs, preexisting implantable cardioverter-defibrillators, a prior surgical aortic valve replacement and any ethnicity other than Hispanic/Latino were all associated with increased odds of NDD.
“The predictors of NDD and 30‐day readmission identified in our study make intuitive sense and are consistent with prior studies,” the authors wrote. “However, our large sample size enabled more independent predictors to be identified than previously reported, including prior SAVR as a predictor of NDD and Hispanic/Latino ethnicity as a predictor of non‐NDD. The latter finding is important and warrants further examination, since disparities in length of stay across race and ethnicity have been documented in patients undergoing several other procedures.”
4. Next-day discharge should be ‘the default strategy’ after TAVR with a self-expanding valve
These consistent outcomes, the authors concluded, suggest NDD should be “the default strategy” for patients undergoing uncomplicated TAVR with an Evolut valve.
“Our data support NDD as the preferred strategy for patients undergoing uncomplicated TAVR who are deemed otherwise suitable for NDD and suggest that valve programs are effective at identifying patients at increased risk of permanent pacemaker implantation/implantable cardioverter‐defibrillator after TAVR versus those at low risk who are appropriate for NDD,” they wrote.
Click here to read the full analysis.