A retrospective analysis, published in Heart, indicates that early discharge (within 72 hours) after transfemoral transcatheter aortic valve implantation (TAVI) in selected patients does not increase the risk of death at 30 days compared with later discharge (after three days). Given that length of hospital stay is a main contributory factor in the costs associated with TAVI, early discharge (when appropriate) may help to reduce costs.
Marco Barbanti (Division of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy) and others report in Heart that the costs of TAVI “are emerging as one of the main limitations for the diffusion of this technique” and that postprocedural length of stay (in hospital) is one of the main factors contributing to these costs. However, they state that “in some cases, hospitalisation after TAVI is likely prolonged without a real clinical need”. Therefore, the aim of their study was to review the feasibility and safety of early discharge (within 72 hours) compared with that of late discharge (after three days) in patients undergoing TAVI with the transfemoral approach.
Of 465 high-risk or inoperable patients who underwent TAVI at the investigators’ centre (Ferrarotto Hospital) between 2007 and 2014, 107 were discharged early. In a multivariate analysis, Barbanti et al found that patients with baseline New York Heart Association IV or any bleeding were less likely to be discharged early whereas those who underwent the procedure more recently (ie. when the operator probably had more experience with TAVI) or who had a permanent pacemaker (Implanted prior to the TAVI procedure) were more likely to be discharged early.
Overall, there were no significant differences between the early discharge group and the late discharge group in terms of the composite safety endpoint of death, bleeding, permanent pacemaker implantation, and re-hospitalisation for any cause occurring after discharge and within 30 days of discharge. There were also no significance differences in a matched comparison of early discharge patients (89) and late discharge patients (178): 3.4% vs. 2.8%, respectively (p=0.533). There were also no differences between groups (in either the matched comparison or the overall comparison) in any of the components of the safety endpoint.
Barbanti et al comment that, because of the costs associated with length of stay after TAVI, it “appears evident that optimisation of hospitalisation length may have a positive effect in containing TAVI costs”. But, they add that the “objective of saving resources has to be achieved without compromising the safety of the procedure in order for a strategy of early discharge to be termed economically attractive.” Therefore, they advise that early discharge should targeted at patients “without a real clinical reason” for having a prolonged hospital stay.
Barbanti told Cardiovascular News: “Patients particularly suitable to early discharge after TAVI are: those not confined to bed before the procedure, those with a low frailty index, those with good mobility, and those with good family support. Also, patients with anatomical and clinical features that do not put them an increased risk of significant complications could be considered for early discharge. Even patients at increased risk of complications have very high chances to be discharged home early and safely if the procedure goes smoothly (eg. no bleeding, renal and conduction disorders issues) and the mobilisation process starts early after the procedure. However, not all transfemoral TAVI patients can be discharged early after the procedure.”