In a recent study published in the Journal of the American College of Cardiology (JACC), it was found that patients undergoing uncomplicated TAVR have a safe next-day discharge (NDD) profile with no difference in 30-day mortality rate in comparison to an increased length of hospital stay. In addition, the study also highlighted better 1-year clinical outcomes in patients as compared to non-NDD group.
Uncomplicated TAVR procedures have made early discharge more feasible. However, there was limited data on determining the predictors, safety, and outcomes of NDD. To address this, Dr. Norihiko Kamioka, M.D and his colleagues conducted a single-center retrospective cohort analysis in patients undergoing TAVR at Emory Hospital.
The investigators reviewed 663 patients who underwent minimalist TAVR from July 2014 to July 2016. The ‘minimalist approach’ was defined as treatment with conscious sedation and local anesthesia using transthoracic echocardiography guidance. Out of 663, 360 patients met the inclusion criteria. Of 360, 150 patients treated were discharged the next day (NDD group) and 210 remained in the hospital beyond 24 hours (non-NDD group). The primary and secondary endpoints were the composite of mortality and readmission at 1 year and 30 days respectively.
The authors identified the predictors of next-day discharge which included male sex, the absence of atrial fibrillation, lower serum creatinine levels, younger age, and a lower Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) score. These findings can be used to determine the possibility of next day discharge.
The study also observed no significant difference in terms of MDCT parameters between the two groups. However, the sheath to femoral artery ratio (the ratio of the minimal femoral artery diameter to sheath outer diameter) was slightly larger in the NDD group.
Similar results were seen between NDD and non-NDD groups with no mortality observed at 30 days. However, the primary composite endpoint at 1 year was significantly lower in the NDD group than in the non-NDD group.
The authors also acknowledged certain limitations to their study. This was a single-center, retrospective, non-randomized observational analysis. Only transfemoral balloon- expandable TAVR population was included. Some patients with chronic kidney disease who could not undergo pre-procedural MDCT were excluded.
Overall, this study confirmed next-day discharge following minimalist TAVR as a strategy in patients without in-hospital complications. Dr. Norihiko Kamioka also stated that these results would require validation through bigger cohort in order to apply NDD to a wider population.