The Vancouver transcatheter aortic valve replacement (TAVR) clinical pathway demonstrated that preprocedure risk stratification planning, reconditioning, using local anesthesia as a default practice, and standardizing postprocedure care with early mobilization can achieve shorter length of hospital stays and excellent outcomes.
TAVR is currently a recommended treatment option for patients with higher-risk or inoperable severe aortic stenosis. While efforts have been made to improve TAVR methods, additional research is needed to determine how best to care for TAVR patients, according to the heart team that developed the Vancouver clinical pathway program.
Since 2005, the Center for Heart Valve Innovation at St. Paul’s Hospital and Vancouver General Hospital has performed more than 1400 TAVR procedures. The median length of hospital stay decreased from 7 to 4 days over 5-year period.
In 2012, the heart team set out to develop a quality improvement initiative in order to optimize outcomes, reduce health service utilization, and contribute to the sustained success of transcatheter heart valve therapies. They sought to reduce variations in care, identify a subgroup of patients suitable for early discharge within 48 hours, and decrease the length of stay for all patients.
The multidisciplinary heart team published their findings in Circulation: Cardiovascular Quality and Outcomes.
Between 2012 and 2014, the team developed a clinical pathway to fit the unique requirements of transfemoral TAVR in contemporary practice—including “risk-stratified minimalist periprocedure approach, standardized postprocedure care with early mobilization and reconditioning, and criteria-driven discharge home.”
They conducted a retrospectively reviewed the cases of 393 consecutive patients, 150 (38.2%) of whom were discharged early. Patients who were discharged early typically had less previous balloon aortic valvuloplasty, higher left ventricular ejection fraction, better cognitive function, and were less frail than the patients who were discharged after 48 hours.
Early discharge was also associated with the use of local anesthesia, implantation of a balloon expandable device, avoidance of urinary catheter, and the early removal of temporary pacemakers.
The median length of hospital stay was 1 day among patients who were discharged early, and 3 days for all other patients. There were no differences between groups in 30-day mortality (1.3%), disabling stroke (0.8%), or readmission (10.7%).
The heart team noted that evidence has also grown supporting the use of TAVR in intermediate surgical risk patients, which will increase the need for a risk-stratified clinical pathway. TAVR programs may also need to increase capacity to meet patient needs in the future.
“Future directions and challenges include studying the value of minimalist TAVR, capitalizing on changes of practice to reduce [length of stay], and facilitating safe transition home to avoid repeat hospitalization,” they concluded.
Lauck SB, Wood DA, Baumbusch J, et al. Vancouver transcatheter aortic valve replacement clinical pathway: Minimalist approach, standardized care, and discharge criteria to reduce length of stay. Circ Cardiovasc Qual Outcomes. 2016. doi: 10.1161/circoutcomes.115.002541.