ABSTRACT
Background: Transcatheter aortic valve replacement (TAVR) with a standardized clinical pathway allows most patients to achieve safe next-day discharge. This approach has been successfully implemented across global centers as part of the Benchmark Program. Considering restricted hospital resources resulting from the COVID-19 pandemic, a modified same day discharge (SDD) clinical pathway was implemented for selected TAVR patients at a single Benchmark site. Methods: All patients accepted for TAVR were assessed for the SDD clinical pathway. Eligibility criteria included adequate social support and accessibility to the TAVR program post-discharge. Patients with preexisting conduction disease were excluded. The clinical pathway comprised of mobilization, bloodwork and electrocardiogram 4 hours post-TAVR and discharge ≥8 hours following groin hemostasis. Results: From June to December 2020, 142 patients underwent TAVR at a single community Benchmark site. Of those, 29 highly selected patients were successfully discharged the same day using the SDD clinical pathway. There were no vascular access complications, permanent pacemaker (PPM) implantation, or mortality in the SDD group during index admission or at 30-day follow-up. When compared to a standard therapy group, there was no statistically significant difference in 30-day cardiovascular readmission. Conclusions: This study demonstrates the safety and feasibility of same day discharge post-TAVR in a highly selected cohort of patients, with no observable difference in safety outcomes when compared to patients who were discharged according to standard institutional practice.Abbreviations: AS: aortic stenosis; ACT: Activated clotting time; AV: atrioventricular; AVB: atrioventricular block; BBB: bundle branch block; CAIC: Canadian Society for Cardiovascular Angiography; CCL: cardiac catheterization laboratory; CT: Computed topography; CV: cardiovascular; IQR: Interquartile Range; IVCD: intraventricular conduction delay; LBBB: left bundle branch block; LOS: length of stay; NDD: next day discharge; PPM: permanent pacemaker; RBBB: right bundle branch block; SCAI: Society for Cardiovascular Angiography and Intervention; SD: standard deviation; SDD: same day discharge; ST: standard therapy; STS PROM: society of thoracic surgeons predicted risk of mortality; TAVR: transcatheter aortic valve replacement; TF: transfemoral; THV: transcatheter heart valve; TTE: transthoracic echocardiogram; VARC: Valve Academic Research Consortium.
ABSTRACT
OBJECTIVES: This study sought to examine the feasibility, safety, and intermediate-term outcomes in patients undergoing percutaneous transvenous transcatheter mitral valve implantation in failed bioprosthesis, ring annuloplasty, and calcific mitral stenosis. BACKGROUND: Surgical mitral valve replacement in patients with previous surgery or severe mitral annular calcification (MAC) is often associated with high or prohibitive risk. METHODS: Percutaneous transfemoral antegrade transseptal implantation of Edwards SAPIEN prosthesis (Edwards Lifesciences, Irvine, California) was performed in 48 patients with degenerated mitral bioprosthesis (n = 33), previous ring annuloplasty (n = 9), and severe MAC (n = 6). RESULTS: The mean Society of Thoracic Surgeons risk score was 13.2 ± 7.4% with a mean age 76 ± 11 years. Acute procedural success was achieved in 42 of 48 patients (88%) in the overall group and 31 of 33 (94%) in the failed bioprosthetic mitral valve group and success rate of 11 of 15 (73%) in patients with failed annuloplasty rings and MAC. After successful procedure, no patients had > mild residual mitral prosthetic or periprosthetic regurgitation; mean transvalvular gradients were 6 ± 2.5 mm Hg. Thirty-day survival free of death and cardiovascular surgery was 85% in the overall group and 91% in the failed bioprosthetic mitral valve subgroup. CONCLUSIONS: Transfemoral percutaneous transvenous mitral valve implantation in high-risk patients with degenerated bioprosthesis is safe, effective, and associated with rapid improvement in hemodynamics, short length of stays, and improved functional status. Percutaneous mitral valve implantation in patients with failed annuloplasty rings and severe MAC is a promising therapy with significant short-term morbidity and mortality that requires further study.