Patients who undergo transfemoral transcatheter aortic valve implantation (TAVI) with a minimalist approach and who are discharged the day after the procedure have similar 30-day outcomes to those who are discharged later. Furthermore, the predictors of next-day discharge include male sex, absence of atrial fibrillation, and lower serum creatinine.
Writing in JACC: Cardiovascular Interventions, Vasilis Babaliaros, Norihiko Kamioka (Division of Cardiology, Emory University School of Medicine, Atlanta, USA) and others report that the minimalist approach—which they describe as “conscious sedation and local anaesthesia using transthoracic echocardiography”—“has made early discharge more feasible after TAVI”. They add the purpose of their study was to identify the predictors of next-day discharge and evaluate the safety of next-discharge at 30 days and at one year.
Of 360 TAVI patients at their centre who underwent transfemoral TAVI with a minimalist approach and with a Sapien XT or Sapien 3 valve (both Edwards Lifesciences), 150 were discharged the next day and 210 were not. After reviewing the baseline characteristics of these patients, Babaliaros and Kamioka et al found male sex, absence of atrial fibrillation, serum creatinine for each increase of 1mg/dl, and age were all predictors of next-day discharge. Noting male sex was the “strongest predictor”, the authors observe that female sex is associated with more vascular complications and more bleeding after TAVI than is male sex “leading to a slightly longer hospital stay for women”. However, they comment that female sex is also associated with better short- and mid-term outcomes after TAVI with older generation devices. “The presence of the sex disparity in our study is intriguing and the need for further examination of sex differences among TAVI patients using current-generation devices,” Babaliaros and Kamioka et al comment.
After excluding patients who had in-hospital complications, the authors compared the safety of next-day discharge among the remaining cohort of 249 (of whom, 132 were in the next-day discharge group). They found that there were no significant differences in the composite rate of 30-day outcomes between groups with no 30-day mortality in either group. The authors comment: “As the rate of readmission at 30 days after minimalist TAVI was reported to be 10.7% by a different group, our results of 30-day composite endpoint (mortality and readmission 6.1%) are similar and support that a next-day discharge is reasonable.”
Furthermore, the one-year composite endpoint was significantly lower in the next-day discharge group. This difference related to a significantly lower incidence of readmission to hospital for non-cardiovascular causes among the next-day discharge patients; there were no differences at one year between groups in the rates of mortality or cardiovascular readmission. According to Babaliaros and Kamioka et al, this finding “probably reflects a healthier cohort in the next-day discharge group”. They add: “Although the reason for the discrepancy in the composite outcome at one year is mainly driven by non-cardiovascular readmission, other cofounding variables cannot be entirely ruled out.”
The authors conclude: “Next-day discharge in patients without in-hospital complications may be appropriate after transfemoral balloon-expandable TAVI.”
“Next day discharge is becoming a new standard with improvement in devices and techniques. More and more centres are using the minimalist approach to achieve these improvements in workflow. Of paramount importance is patient safety and therefore we recommend this method and next day discharge only in appropriate patients,” Babaliaros told Cardiovascular News.