Early Discharge Following Uncomplicated TAVR Safe, According to a Meta-Analysis

A recent meta-analysis published in the Journal of American College of Cardiology has shown that early discharge (ED) after uncomplicated Transaortic valve replacement (TAVR) is safe and has no negative impact on discharge to 30-day mortality or the need for permanent pacemaker insertion (PPI).

This meta-analysis included eight studies with 1,775 patients. The reported median intensive care unit (ICU) length of stay for early discharge (ED) patients was less than equal to 1 day, whereas median ICU length of stay among standard discharge (SD) patients varied from 1 to 4 days. The authors concluded that employment of a conservative approach by using transfemoral access, transthoracic echocardiography, and conscious sedation or local anesthesia in the ED group in addition to discharge by day 3 after TAVR was safe in terms of discharge to 30-day mortality (Odds ratio[OR]:0.65; 95% Confidence Interval [CI]: 0.23-1.82; p=0.04). Interestingly, it was also found that the 642 patients included in the ED group had a significantly lower readmission rate compared with SD patient group (OR: 0.63, 95% CI: 0.41-0.98; p=0.04). The authors attributed the lower readmission rate in the ED group to increasing incidence of healthcare-associated infections per day of stay and a higher co-morbidity burden in the SD group.

Dr. Rodrigo Bagur, the co-author of the study and an interventional cardiologist at London Health Science Centre commented, “There is a marked variability in institutional discharge programs/protocols, suggesting a limited evidence basis around best practice and hence, our study represents an important synthesis of available evidence.”

 

 

 

Two out of the eight studies included in the meta-analysis reported the causes of death within 30 days of discharge. All deaths were due to cardiovascular causes and occurred 7 days post TAVR, implying that prolonged stay would have not prevented the occurrence of these deaths.

Although this meta-analysis defined ED as discharge within 3 days after TAVR, other studies have shown that next-day discharge after TAVR is safe as well. Therefore, registries such as FAST-TAVI and 3MTAVR need to be analyzed in order to have a better idea of the optimal discharge window. Emphasizing on the importance of the study, Dr. Bagur states, “These data support the safety of current programs aiming an ED pathway in selected patients undergoing TAVR. Institutional protocols with the input from different members of the multidisciplinary heart team should be devised to optimize discharge pathways and, hence, help improve healthcare resource utilization.”

One limitation of the meta-analysis is the small number of studies included in the analysis and the small number of patients in each event. Also, ED patients tend to have fewer comorbidities. Therefore, the probability of complications in this group is lower.

Source: http://interventions.onlinejacc.org/content/11/17/1759