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Early Versus Standard Discharge After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis
Authors:Rafail A. Kotronias  Michael Teitelbaum  John G. Webb  Darren Mylotte  Marco Barbanti  David A. Wood  Brennan Ballantyne  Alyson Osborne  Karla Solo  Chun Shing Kwok  Mamas A. Mamas  Rodrigo Bagur
Affiliation:1. Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom;2. Oxford University Clinical Academic Graduate School, Oxford University, Oxford, United Kingdom;3. London Health Sciences Centre, London, Ontario, Canada;4. Centre for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada;5. Galway University Hospitals, National University of Ireland, Galway, Ireland;6. Division of Cardiology, Cardio-Thoracic-Vascular Department, University of Catania, Catania, Italy;7. Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada;8. The Heart Centre, Royal Stoke Hospital, University Hospital of North Midlands Trust, Stoke-on-Trent, United Kingdom
Abstract:

Objectives

This study sought to assess the clinical outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) with early discharge (ED) versus standard discharge (SD) pathways.

Background

Minimalist approaches for TAVR have been developed targeting different aspects of the procedure such as local anesthesia or sedation, intraprocedural imaging, vascular access, post-operative monitoring and care, and discharge planning. Their incorporation into routine clinical practice aims to reduce length of hospital stay and health care cost utilization without adversely affecting outcomes when compared with standard approaches.

Methods

The authors conducted a search of MEDLINE and EMBASE to identify studies that investigated ED (≤3 days) versus SD in TAVR patients. Random-effects meta-analyses were used to estimate the effect of ED compared with SD with regard to 30-day mortality after discharge, 30-day readmission rate, and need for permanent pacemaker implantation (PPI) following discharge.

Results

Eight studies including 1,775 participants (ED, n = 642) fulfilled the inclusion criteria. The mean age was 82.4 years and STS score was 6.7. Meta-analyses evaluating discharge to 30-day mortality (odds ratio [OR]: 0.65; 95% confidence interval [CI]: 0.23 to 1.82; I2 = 0%) and discharge to 30-day new PPI (OR: 1.61; 95% CI: 0.19 to 13.71; I2 = 40%) showed no significant difference in an ED compared with a SD strategy. Notably, ED patients were less likely to be readmitted after ED when compared with SD patients (OR: 0.63; 95% CI: 0.41 to 0.98; p = 0.04, I2 = 0%).

Conclusions

ED following uncomplicated TAVR is safe in terms of discharge to 30-day mortality or need for PPI following discharge. Moreover, ED patients experienced a lower rate of readmissions. These data support the safety of programs aiming an ED pathway in selected TAVR patients. Institutional protocols with the input from different members of the multidisciplinary heart team should be devised to optimize discharge processes to improve health care resource utilization.
Keywords:aortic stenosis  early discharge  readmission  TAVR  transcatheter  CI  confidence interval  ED  early discharge  ICU  intensive care unit  LoS  length of stay  OR  odds ratio  PPI  permanent pacemaker implantation  SD  standard discharge  TAVR  transcatheter aortic valve replacement
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