From the Journals

Next-day discharge after TAVR shows promise

 

Key clinical point: Next-day discharge (NDD) after minimalist TAVR appeared safe, compared with a longer hospital stay.

Major finding: The composite endpoint of mortality and readmission at 30 days was similar between groups (HR, 0.62; 95% CI, 0.20-1.91), and was lower in the NDD arm at 1 year because of fewer noncardiovascular readmissions.

Data source: A single-center, retrospective, nonrandomized observational analysis comprising 663 consecutive patients who underwent elective balloon-expandable TAVR between July 2014 and July 2016.

Disclosures: Study authors reported disclosures related to Edwards Lifesciences, Abbott Vascular, Medtronic, Gore Vascular, and Boston Scientific.

Source: JACC: Cardiovasc Interven. doi: 10.1016/j.jcin.2017.10.021.

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Next-day discharge: Consequence of optimized care?

Researchers at Emory University have been leaders in promoting the so-called minimalist approach to TAVR and helping others understand how to safely reduce the length of stay without reducing the quality of care in these patients; however, the present study has significant shortcomings” that “may raise more questions than answers.

Dr. Molly Szerlip The Heart Hospital Baylor Plano The Heart Hospital Baylor Plano

Dr. Molly Szerlip

The study was based on a highly selective patient population that excluded patients who had received general anesthesia, had a complication, received a self-expanding valve, or did not undergo a preprocedure three-dimensional multidetector computed tomography (MDCT); as a result, only 150 patients out of 663 (23%) had next-day discharge (NDD) after TAVR.

Because of these exclusions, it is difficult to know from this study if this treatment is generalizable to a larger TAVR population.

The conclusion that there was no difference in the composite outcome of death and readmission at 30 days is helpful information, offering reassurance that patient safety is not being compromised with NDD; however, the finding of superior outcomes at 1 year in the NDD group was driven by a significant reduction in noncardiovascular readmissions, which merely reemphasizes that the NDD patients in this study were lower risk rather than that they benefited by NDD.

Molly Szerlip, MD, of the Heart Hospital Baylor Plano (Tex.) made these comments in an accompanying editorial (JACC: Cardiovasc Interven. 2018 Jan 22. doi: 10.1016/j.jcin.2017.12.001). She reported disclosures related to Edwards Lifesciences and Medtronic.


 

FROM JACC: CARDIOVASCULAR INTERVENTIONS

Compared with a longer hospital stay, next-day discharge (NDD) after minimalist transcatheter aortic valve replacement (TAVR) appears safe, according to a recently reported analysis of patients treated at a single center.

The composite endpoint of mortality and readmission at 30 days was similar for NDD, compared with later discharges among patients who had a procedure that met minimalist criteria, defined in this study as transfemoral TAVR under conscious sedation and local anesthesia.

Mortality and readmission at 1 year was lower in the NDD group, mainly because of a lower risk of noncardiovascular readmissions, study authors reported in JACC: Cardiovascular Interventions. “Although superior NDD outcomes are likely attributed to selected patient characteristics, NDD in patients without in-hospital complications may be appropriate after transfemoral balloon-expandable TAVR,” wrote Norihiko Kamioka, MD, division of cardiology, Emory University, Atlanta, and associates.

The retrospective, observational analysis included 663 consecutive patients who underwent elective balloon-expandable TAVR during July 2014–July 2016. Cases with complications after the procedure were excluded.

The final analysis, which included 150 patients who had NDD and 210 discharged later, showed no difference between groups in the composite endpoint of mortality, and that 30-day readmissions were similar between groups (hazard ratio, 0.62; 95% confidence interval, 0.20-1.91).

Mortality and readmission at 1 year, the primary endpoint chosen for the study, favored the NDD group (HR, 0.47; 95% CI, 0.27-0.81), but “this finding probably reflects a healthier cohort in the NDD group,” the investigators noted. Furthermore, “although the reason for the discrepancy in the composite outcome at 1 year is mainly driven by noncardiovascular readmission, other confounding variables cannot be entirely ruled out,” Dr. Kamioka and colleagues said in the report.

Predictors of NDD included male sex, no atrial fibrillation, lower serum creatinine level, and younger age, researchers also found.

A validation cohort would be needed to confirm the findings of this study, including predictors of favorable outcomes, and to apply NDD to a wider population, study authors said.

Dr. Kamioka reported no relationships relevant to the study. Study coauthors reported disclosures related to Edwards Lifesciences, Abbott Vascular, Medtronic, Gore Vascular, and Boston Scientific.

SOURCE: JACC: Cardiovascular Interventions. 2018 Jan 22. doi: 10.1016/j.jcin.2017.10.021.

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