Short Length of Stay After Elective Transfemoral Transcatheter Aortic Valve Replacement is Not Associated With Increased Early or Late Readmission Risk

Outcomes of transcatheter vs surgical aortic valve replacement in pre-existing chronic liver disease patients: A meta-analysis of observational studies

Aortic valve stenosis in patients with chronic liver diseases, particularly liver cirrhosis and End-Stage Liver Disease, poses significant management challenges due to the interplay between cardiovascular and hepatic dysfunction. This systematic review and meta-analysis compared the safety and efficacy of Transcatheter Aortic Valve Replacement (TAVR) and Surgical Aortic Valve Replacement in this high-risk population. An extensive search of PubMed, Embase, and Web of Science (inception to January 5, 2025) identified 11 retrospective studies comprising 19,097 patients. Risk ratios for dichotomous outcomes and mean differences (MD) for continuous outcomes, each with 95% confidence intervals, were calculated using random-effects models. The analysis revealed that TAVR significantly reduced hospital mortality (RR 0.36, 95 % CI: 0.30-0.42; I2 = 7.6 %), acute kidney injury (RR 0.51, 95 % CI: 0.33-0.78; I2 = 57.2 %), bleeding (RR 0.33, 95 % CI: 0.28-0.39; I2 = 0.0 %), stroke (RR 0.35, 95 % CI: 0.23-0.51; I2 = 6.1 %), and blood transfusion (RR 0.48, 95 % CI: 0.40-0.57; I2 = 7.6 %). TAVR was also associated with shorter hospital stays (MD -6.77 days, 95 % CI: -9.17 to -4.38; I2 = 97.5 %). No significant differences were observed in vascular complications requiring surgery or hospital charges and post-operative infections. These findings suggest TAVR offers significant advantages over SAVR in reducing complications such as mortality, acute kidney injury, and bleeding in patients with liver disease. However, further randomized trials are necessary to confirm long-term outcomes and establish optimal treatment strategies for this high-risk population.

Biomimetic multilayered polymeric heart valve featuring ultra-thin thickness and exceptional durability

The transcatheter aortic valve replacement technique has rapidly developed in clinical practice, with its indications expanding to low-risk populations and younger patients. The durability of valve materials has emerged as a critical requirement from a clinical perspective and a research focus in interventional valves. Polymeric heart valves exhibit a promising future because of their enhanced durability and reduced cost. Herein, we developed biomimetic multilayered polymeric heart valves (BMPHVs) utilizing thermoplastic silicone-polycarbonate polyurethane and ultra-high molecular weight polyethylene fibers, selected to replicate the fibrosa, spongiosa, and ventricular layers in natural heart valves. The construction process involved the fabrication of ultra-strong, ultra-fine fiber textiles and leaflet laser cutting utilizing edge-sealing technology. BMPHVs exhibit superior durability than bovine pericardial valves. These findings facilitate the development of a new category of advanced synthetic materials characterized by long-term durability for valve replacement.

Burden of hospitalization during the first year following transcatheter and surgical aortic valve replacement

BACKGROUND

Hospitalizations are a major burden for both patients and society but are potentially preventable. We examined the one-year hospitalization burden in patients undergoing transcatheter aortic valve replacement (TAVR) and compared hospitalization rates and patterns with those undergoing isolated surgical aortic valve replacement (SAVR).

METHODS

Using Danish nationwide registries, we identified patients who underwent first-time TAVR and isolated SAVR (2008-2019), respectively. Subsequent hospitalizations were classified as cardiovascular or noncardiovascular according to discharge diagnosis codes.

RESULTS

Patients undergoing TAVR (N = 4,921) were older and had more comorbidities than those undergoing SAVR (N = 5,220). There were 5,725 and 4,426 hospitalizations within the first year after discharge in the TAVR and SAVR group, respectively. During the one-year follow-up period post-TAVR, 46.6% were not admitted, 25.4% were admitted once, 12.6% twice, and 15.4% 3 times or more. The corresponding proportions in patients undergoing SAVR were 55.3%, 25.1%, 10.0%, and 9.5%, respectively. Among patients with ≥1 hospitalization following TAVR, 50.3% had a total length of all hospital stays between 1 and 7days, 19.0% 8-14days, 18.0% 15-30days, 9.9% 31-60days, and 2.8% ≥61days. The corresponding proportions for patients undergoing SAVR were 58.6%, 17.2%, 13.1%, 7.4%, and 3.7%, respectively. Compared with patients undergoing SAVR, those undergoing TAVR had a lower early (day0-30: HR 0.89 [95% CI, 0.80-0.98]), but a higher late hospitalization rate (day 31-365: 1.46 [1.32-1.60]).

CONCLUSIONS

The 1-year hospitalization burden following TAVR is substantial. Compared with patients undergoing isolated SAVR, those undergoing TAVR had a lower early, but a higher late hospitalization rate - a difference that likely reflects unmeasured differences in the patient cohorts.

Incidence, predictors, and prognostic impact of rehospitalization after transcatheter aortic valve implantation

AIMS

Despite rehospitalization being common after transcatheter aortic valve implantation (TAVI), an in-depth analysis on this topic is missing. This study sought to report on the incidence, predictors, and prognostic impact of rehospitalization within 1 year following TAVI.

METHODS AND RESULTS

All consecutive patients treated with TAVI between 2016 and 2020 in East Denmark were included. Medical records of all patients were reviewed to validate rehospitalizations up to 1 year after discharge from the index admission. The study population consisted of 1397 patients, of whom 615 (44%) had an unplanned rehospitalization within the first year post-TAVI. The rehospitalization incidence rate was three-fold higher in the early period (within 30 days) compared with the late period (30 days to 1 year; 2.5 vs. 0.8 per patient-year, respectively; P < 0.001). Predictors of early unplanned rehospitalization were procedure-related complications and prior stroke, whereas late unplanned rehospitalization was associated with preexisting comorbidities. Predictors of heart failure (HF) rehospitalization included ischaemic heart disease, the extent of cardiac damage, atrial fibrillation, and New York Heart Association class at baseline. HF rehospitalization within 30 days and 1 year post-TAVI was associated with a markedly increased 1- and 5-year mortality risk [hazard ratio (HR) of 4.3 and 3.2 for 1-year mortality and HR of 3.2 and 2.9 for 5-year mortality, respectively; P< 0.001].

CONCLUSIONS

Rehospitalization after TAVI is frequent in real-world practice. Early rehospitalization is mostly procedure related, whereas late rehospitalization is related to preexisting comorbidities. HF rehospitalization is associated with poor long-term survival and could be validated as a prognostically relevant endpoint for TAVI trials.

Evolving Paradigms in Transcatheter Aortic Valve Replacement: Results from a High-Volume, Single Center Experience

Given the expanding indications toward younger patients at lower surgical risk, transcatheter aortic valve replacement (TAVR) simplification and streamlining are gaining increasing importance. Patients who underwent TAVR from the year 2015 to 2020 were prospectively enrolled. The patients were divided in time tertiles according to the date of intervention. Data on preprocedural planning, including coronary computed tomography angiography (CCTA), procedures, and outcomes, were compared between the time tertiles. A total of 771 consecutive patients from a single institution were enrolled. We observed a trend toward the use of a fully percutaneous versus surgical approach for the index access, left radial artery versus contralateral femoral artery for the secondary access, and left ventricular pacing on the stiff guidewire versus right ventricular pacing. Immediate device success significantly increased, whereas the length of hospital stay decreased. Overall, approximately 60% of the total study population underwent CCTA instead of coronary angiography, with no adverse events. One-year survival rates significantly improved over time. A simplified TAVR approach was associated with better survival, whereas low baseline functional capacity, preexisting coronary artery disease, renal impairment, periprocedural blood transfusions, and paravalvular leak were related to worse outcomes. In conclusion, our study showed a constant tendency to procedure streamlining and improve procedural success and 1-year outcomes. A strategy based on CCTA allows sparing safely almost half of the preoperative invasive coronary angiography.

Temporal Trends in Internal vs. External Referrals for TAVR in a Large Academic Center: Patients Characteristics and Outcomes

Background

Since transcatheter aortic valve replacement (TAVR) first became approved for inoperable patients followed by high, intermediate-, and low-risk patients, referrals to TAVR centers have rapidly increased. The purpose of this study was to investigate referral patterns to a large academic TAVR center in the state of North Carolina and evaluate differences between externally and internally referred patients.

Methods

Data for all patients who underwent TAVR at our institution between November 2014 and March 2020 were pulled from the Transcatheter Valve Therapy Registry. The electronic medical record was used to determine the referral source. The descriptive statistical analysis was performed using Excel (Microsoft, Redmond, Washington).

Results

491 patients underwent TAVR at our institution between November 2014 and March 2020. Half of the patients were referred by a cardiologist within the same health system (N = 250, 50.9%). Other referral sources included a cardiologist external to the health system (N = 210, N = 42.8%) and a surgeon or proceduralist (such as urologist, surgeon, or gastroenterologist) during the workup for another procedure (N = 26, 5.3%). Over time, there was a trend toward an increasing proportion of patients referred by a cardiologist external to our system, but this trend did not reach statistical significance (20.0% in 2014, 29.2% in 2015, 30.7% in 2016, 53.0% in 2017, 36% in 2018, 48.4% in 2019, and 56.8% in 2020, p=0.06 using the Mann–Kendall trend test). Externally referred patients were less likely to have private insurance and were more likely to have a reduced ejection fraction and had a higher mean gradient across the valve. Postprocedure, externally referred patients were more likely to have the procedure under moderate sedation and less likely to be discharged home.

Conclusions

This study presents the referral pattern to a large TAVR center in North Carolina. Over time, there was an increase in external referrals suggesting that TAVR is increasingly adopted as an important component of the management of aortic valve stenosis. Internally and externally referred patients have differences in baseline demographic and clinical characteristics which may have an impact on clinical outcomes.

Reducing length of stay for patients undergoing transcatheter aortic valve replacement using a prescreening approach

BACKGROUND

As transcatheter aortic valve replacement (TAVR) becomes a preferred treatment option for patients with aortic valve stenosis, and demand for TAVR increases, it is imperative that length of stay (LOS) is reduced while maintaining safety and effectiveness.

LOCAL PROBLEM

As TAVR procedures have become less invasive and more streamlined, current protocols have not been updated to reflect today's postprocedure requirements.

METHODS

The next-day discharge (NDD) protocol was established using available literature. A convenience sample was evaluated for NDD protocol inclusion during aortic multidisciplinary team conference using predetermined inclusion and exclusion criteria. Length of stay for NDD protocol participants was compared with LOS from a retrospective convenience sample of patients undergoing TAVR in the time frame mirroring NDD protocol initiation of the year prior.

INTERVENTIONS

Patients meeting inclusion criteria were enrolled in the NDD protocol with a goal of discharge to home on postprocedural day 1 by 2:00 p.m. The NDD protocol included preprocedure expectation setting, prescheduled same-day postprocedure imaging, and discharge priority on postprocedure day 1.

RESULTS

There is a significant difference in LOS between the NDD eligible retrospective and prospective groups. The prospective group has a significantly lower LOS than the retrospective group (M = 1.6 vs 2.1, respectively; p = .0454).

CONCLUSIONS

An NDD protocol can help reduce LOS after TAVR in appropriately selected patients. Further protocol revision will be required to optimize LOS outcomes.

Financial Incentives for Transcatheter Aortic Valve Implantation in Ontario, Canada: A Cost-Utility Analysis

Background

Transcatheter aortic valve implantation (TAVI) is a minimally invasive therapy for patients with severe aortic stenosis, which has become standard of care. The objective of this study was to determine the maximum cost‐effective investment in TAVI care that should be made at a health system level to meet quality indicator goals.

Methods and Results

We performed a cost‐utility analysis using probabilistic patient‐level simulation of TAVI care from the Ontario, Canada, Ministry of Health perspective. Costs and health utilities were accrued over a 2‐year time horizon. We created 4 hypothetical strategies that represented TAVI care meeting ≥1 quality indicator targets, (1) reduced wait times, (2) reduced hospital length of stay, (3) reduced pacemaker use, and (4) combined strategy, and compared these with current TAVI care. Per‐person costs, quality‐adjusted life years, and clinical outcomes were estimated by the model. Using these, incremental net monetary benefits were calculated for each strategy at different cost‐effectiveness thresholds between $0 and $100 000 per quality‐adjusted life year. Clinical improvements over the current practice were estimated with all comparator strategies. In Ontario, achieving quality indicator benchmarks could avoid ≈26 wait‐list deaths and 200 wait‐list hospitalizations annually. Compared with current TAVI care, the incremental net monetary benefit for this strategy varied from $10 765 (±$8721) and $17 221 (±$8977). This would translate to an annual investment of between ≈$14 to ≈$22 million by the Ontario Ministry of Health to incentivize these performance measures being cost‐effective.

Conclusions

This study has quantified the modest annual investment required and substantial clinical benefit of meeting improvement goals in TAVI care.

Relation of Subacute Kidney Injury to Mortality After Transcatheter Aortic Valve Implantation

Acute kidney injury after transcatheter aortic valve implantation (TAVI) has been associated with adverse outcomes; however, data are limited on the subacute changes in renal function that occur after discharge and their impact on clinical outcomes. This study investigates the relation between subacute changes in kidney function at 30 days after TAVI and survival. Patients from 2 centers who underwent TAVI and survived beyond 30 days with baseline, in-hospital, and 30-day measures of renal function were retrospectively analyzed. Patients were stratified based on change in estimated glomerular filtration rate (eGFR) from baseline to 30 days as follows: improved (≥15% higher than baseline), worsened (≤15% lower), or unchanged (values in between). Univariable and multivariable models were constructed to identify predictors of subacute changes in renal function and of 2-year mortality. Of the 492 patients who met inclusion criteria, eGFR worsened in 102 (22%), improved in 110 (22%), and was unchanged in 280 (56%). AKI occurred in 90 patients (18%) and in only 27% of patients with worsened eGFR at 30 days. After statistical adjustment, worsened eGFR at 30 days (hazard ratio vs unchanged eGFR 2.09, 95% CI 1.37 to 3.19, p <0.001) was associated with worse survival, whereas improvement in renal function was not associated with survival (hazard ratio vs unchanged eGFR 1.30, 95% CI 0.79 to 2.11, p = 0.30). Worsened renal function at 30 days after TAVI is associated with increased mortality after TAVI. In conclusion, monitoring renal function after discharge may identify patients at high risk of adverse outcomes.

Real-life outcomes and readmissions after a TAVI procedure in a Glasgow population

Transcatheter aortic valve implantation (TAVI) is a routine procedure for patients with symptomatic severe aortic stenosis who are deemed inoperable or high-risk surgical candidates. The aim of this study was to examine real-world data on death and readmission rates in patients following the procedure. Electronic health records for patients who underwent TAVI between April 2015 and November 2018 were reviewed. Details of the procedure, complications, length of initial hospital stay and outcomes of interest (subsequent admissions and mortality) were recorded. In our cohort of 124 patients, the mean age was 80.8 years and 43% were male. Cardiac comorbidities were common, more than 30% had myocardial infarction (MI) and 15% had a previous coronary artery bypass graft (CABG). One in five suffered from chronic obstructive pulmonary disease (COPD), with similar prevalence of diabetes mellitus and cerebrovascular accident (CVA). In-hospital mortality was low at 3.3%, however, 30-day readmission rates were high at 14.6%; 44.4% were readmitted to hospital within one year. TAVI is a successful procedure in Scotland with good outcome data. The potential benefit of the procedure in many patients is limited by comorbidities, which shorten life-expectancy and lead to hospital readmission. These data highlight the importance of effective multi-disciplinary discussion in a time of realistic medicine.

Impact of early hospital discharge on clinical outcomes after transcatheter aortic valve implantation

AIMS

Early discharge after transcatheter aortic valve implantation (TAVI) may potentially impact post-procedural safety of the patient. The study aim was to compare safety of TAVI in patients planned for fast track hospital stay with patients planned for standard hospital stay.

METHODS AND RESULTS

All-comers patients undergoing transfemoral TAVI between 2011 and 2017 were allocated to two matched groups depending whether the procedure was performed before or after transition from standard to fast track course. Data on vital status and hospitalizations were obtained through national registries. Three hundred and nineteen matched pairs were eligible for analysis. The median length of post-procedural stay was 3 days (IQR: 2-4) for patients in the fast track group compared to 6 days (IQR: 4-8) in the standard approach group (p < .0001). There was no difference in all-cause mortality between groups at 30-day (1.3% vs. 1.9%, p = .52) or 90-day follow-up (2.9% vs. 4.1%, p = .42). There was no difference in the risk of new permanent pacemaker implantation (PPI) in pacemaker naïve patients between groups at 30-day (15.8% vs. 21.2%, p = .16) or 90-day follow-up (15.8% vs. 21.9%, p = .12). There was no difference in the rate of rehospitalization between groups between discharge and 90-day follow-up (2.09 per patient-year vs. 2.09 per patient-year, p = .99).

CONCLUSIONS

Early discharge in an all-comers population undergoing transfemoral TAVI is safe with regards to all-cause mortality, need for PPI, and rehospitalization.

Clinical process optimization of transfemoral transcatheter aortic valve implantation

Background: The avoidance of prolonged hospital stay is a major goal in the management of transcatheter aortic valve implantation (TAVI) - medically and economically. Materials & methods: We compared the time range of the preprocedural length of stay in 2014/2015 with 2016/2017, after the implementation of the TAVI coordinator in 2016. This included restructured pathways for screening and pre-interventional diagnosis, performed examinations during the inpatient stay and major outcome variables. Results: After 2016, we observed a significant reduction in preprocedural length of stay (admission to procedure) compared with 2014/2015 (11.3 ± 7.9 vs 7.5 ± 5.6 days, p = 0.001). There was no difference in other major outcome variables. Conclusion: The introduction of the TAVI coordinator caused a shortening of preprocedural length of stay.

Very Early Changes in Quality of Life After Transcatheter Aortic Valve Replacement: Results From the 3M TAVR Trial

BACKGROUND

Patients with severe, symptomatic aortic stenosis derive substantial 30-day quality of life (QOL) benefit from transcatheter aortic valve replacement (TAVR). Whether the QOL benefit of TAVR emerges earlier is unknown. We used data from the Multimodality, Multidisciplinary but Minimalist (3M) TAVR study to assess early changes in QOL after transfemoral (TF) TAVR.

METHODS

Health status was assessed at baseline, 2-weeks, 30-days, and 1-year after TAVR using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Medical Outcomes Study Short-Form 12 (SF-12). The KCCQ overall summary (KCCQ-OS) score (range 0-100; higher scores = better health) was the primary health status outcome. Linear mixed effects models were used to describe trajectories of QOL scores over time. A good outcome was defined as being "alive and well", with a KCCQ-OS score ≥ 60 points with no decrease from baseline ≥10 points.

RESULTS

A total of 358 patients (87.1%) completed the baseline and at least one follow-up survey. Between baseline and 2-weeks, the KCCQ-OS increased by 21.3 points (95% confidence interval [CI]: 19.3-23.2). This improvement was sustained over time with only slight further improvement between 2-weeks and 1-month (3.4 points; 95% CI: 1.4 to 5.5) and no significant change between 1-month and 1-year (1.9 points; 95% CI: -0.2 to 4.1). Scores for the KCCQ subscales and SF-12 physical and mental component summary scales showed a similar pattern. Most patients (74.4%) were "alive and well" at 2 weeks with similar rates at 1-month and 1-year (79.5% and 77.3%, respectively).

CONCLUSIONS

Among patients undergoing TF-TAVR, both disease-specific and generic health status improved substantially within the first 2 weeks, with only minimal further improvement thereafter.

Association Between Wait Time for Transcatheter Aortic Valve Replacement and Early Postprocedural Outcomes

Background

Rapid growth in transcatheter aortic valve replacement (TAVR) demand has translated to inadequate access, reflected by prolonged wait times. Increasing wait times are associated with important adverse outcomes while on the wait‐list; however, it is unknown if prolonged wait times influence postprocedural outcomes. Our objective was to determine the association between TAVR wait times and postprocedural outcomes.

Methods and Results

In this population‐based study in Ontario, Canada, we identified all TAVR procedures between April 1, 2010, and March 31, 2016. Wait time was defined as the number of days between initial referral and the procedure. Primary outcomes of interest were 30‐day all‐cause mortality and all‐cause readmission. Multivariable regression models incorporated wait time as a nonlinear variable, using cubic splines. The study cohort included 2170 TAVR procedures, of which 1741 cases were elective and 429 were urgent. There was a significant, nonlinear relationship between TAVR wait time and post‐TAVR 30‐day mortality, as well as 30‐day readmission. We observed an increased hazard associated with shorter wait times that diminished as wait times increased. This statistically significant nonlinear relationship was seen in the unadjusted model as well as after adjusting for clinical variables. However, after adjusting for case urgency status, there was no relationship between wait times and postprocedural outcomes. In sensitivity analyses restricted to either only elective or only urgent cases, there was no relationship between wait times and postprocedural outcomes.

Conclusions

Wait time has a complex relationship with postprocedural outcomes that is mediated entirely by urgency status. This suggests that further research should elucidate factors that predict hospitalization requiring urgent TAVR while on the wait list.

Effect on 30-Day Readmissions after Early Versus Delayed Discharge after Uncomplicated Transcatheter Aortic Valve Implantation (from the Nationwide Readmissions Database)

Early discharge after transcatheter aortic valve implantation has been shown to be safe in single-center studies and trials, but outcomes in broader clinical practice are unknown. Using the National Readmission Databases (1/2014 to 9/2015), we compared 30-day readmission rates between early (<3 days) and late (≥3 days) discharges after uncomplicated endovascular TAVR in a propensity-matched cohort. We examined factors associated with failure of early discharge by testing for interactions of patient factors with discharge strategy. Among 4,955 hospitalizations for uncomplicated TAVR, 1,857 (37%) were discharged early with substantial site-level variability (range 0% to 87%; median odds ratio 3.69). In the propensity matched cohort (n = 3,346), there were similar rates of 30-day readmission by discharge strategy (early vs late: 10.3% vs 10.6%; stratified log-rank p = 0.555). There was a statistically significant interaction between discharge strategy and number of chronic conditions (p = 0.007), where readmission rates were lower in patients discharged early in those with 0 to 4 chronic conditions, but not in those with 5 to 10 or >10. In conclusion, in a large "real-world" cohort, early discharge after uncomplicated TAVR was not associated with a higher rate of 30-day rehospitalization, yet there was significant variability across US hospitals. No patient characteristics were associated with increased risk of readmission with early discharge.

Identifying patients likely to be readmitted after transcatheter aortic valve replacement

Hospital readmission following transcatheter aortic valve replacement (TAVR) contributes considerably to the costs of care. Readmission rates following TAVR have been reported to be as high as 17.4% at 30 days and 53.2% at 1 year. Patient and procedural factors predict an increased likelihood of readmission including non-transfemoral access, acute and chronic kidney impairment, chronic lung disease, left ventricular systolic dysfunction, atrial fibrillation, major bleeding and prolonged index hospitalisation. Recent studies have also found the requirement for new pacemaker implantation and the severity of paravalvular aortic regurgitation and tricuspid regurgitation to be novel predictors of readmission. Post-TAVR readmission within 30 days of discharge is more likely to occur for non-cardiac than cardiac pathology, although readmission for cardiac causes, especially heart failure, predicts higher mortality than readmission for non-cardiac causes. To combat the risk of readmission and associated mortality, the routine practice of calculating and considering readmission risk should be adopted by the heart team. Furthermore, because most readmissions following TAVR occur for non-cardiac reasons, more holistic approaches to readmission prevention are necessary. Familiarity with the most common predictors and causes of readmission should guide the development of initiatives to address these conditions proactively.

A comparative profitability analysis of transcatheter versus surgical aortic valve replacement in a high-volume French hospital

BACKGROUND

Current scientific guidelines have extended the indication for transcatheter aortic valve replacement (TAVR) to patients who present an intermediate risk for surgery and have been so far considered for conventional surgery. We previously demonstrated that the TAVR procedure generated profits despite elevated costs, but comparison with surgery has not been performed. The objective of this study was to assess the profitability of the TAVR procedure compared with conventional surgery in a high-volume French hospital. Consecutive patients eligible for transfemoral TAVR or surgical aortic valve replacement (SAVR) were included retrospectively in this single-centre study between September 2014 and December 2015. The primary endpoint was the profitability of each procedure (defined as the ratio between the profit and total revenues), calculated for each patient. Secondary composite endpoints included major adverse events in the 30 days following procedure and breakdown of costs.

RESULTS

Two hundred and thirty-eight patients were included in the TAVR group and 341 in the SAVR group. TAVR patients presented higher operative risk scores and more comorbidities. Compared with SAVR, TAVR was associated with higher profits (€2732 ± 1768 per patient vs. €2177 ± 2437 per patient, P < 0.001) but also higher costs (€27,778 ± 4961 vs. €17,813 ± 6071, P < 0.001) resulting in lower profitability (9.3 ± 5.7% vs. 11.7 ± 10.1%, P < 0.001). The price of the bioprosthesis represented 70% of the TAVR total cost.

CONCLUSIONS

TAVR performed in carefully selected patients was associated with higher profits than SAVR, but also higher costs resulting in lower profitability.

Simplification and optimization of transcatheter aortic valve implantation - fast-track course without compromising safety and efficacy

Transcatheter aortic valve implantation (TAVI) has become an established therapeutic option for patients with symptomatic, severe aortic valve stenosis. Ageing of the Western and Asian population and expansion of indications for TAVI will lead to a substantial increase in the number of TAVI procedures performed worldwide within the next decades. In line with the maturation of TAVI over the past few years, there has also been a significant simplification and optimisation of the TAVI procedure. A minimalist TAVI procedure and fast-track TAVI course have been shown to have distinct advantages over the more traditional TAVI approach. The aim of this manuscript is to discuss strategies of TAVI simplification and optimization, with special focus on fast-track TAVI, without compromising safety and efficacy.

The Impact of Discharge Timing on Readmission Following Hepatopancreatobiliary Surgery: a Nationwide Readmission Database Analysis

OBJECTIVE

Decreasing hospital length-of-stay (LOS) may be an effective strategy to reduce costs while also improving outcomes through earlier discharge to the non-hospital setting. The objective of the current study was to define the impact of discharge timing on readmission, mortality, and charges following hepatopancreatobiliary (HPB) surgery.

METHODS

The Nationwide Readmissions Database (NRD) was used to identify patients undergoing HPB procedures between 2010 and 2014. Length of stay (LOS) was categorized as early discharge (4-5 days), routine discharge (6-9 days), and late discharge (10-14 days). Univariable and multivariable analyses were utilized to identify factors associated with 90-day readmission.

RESULTS

A total of 28,114 patients underwent HPB procedures. Overall median LOS was 7 days (IQR 5-11); 10,438 (37.1%) patients had an early discharge, while 13,665 (48.6%) and 4011 (14.3%) patients had a routine or late discharge. The probability of early discharge increased over time (referent 2010: 2011-4% (OR 1.04, 95% CI 0.96-1.15) vs. 2012-10% (OR 1.10, 95% CI 1.01-1.20) vs. 2013-21% (OR 1.21, 95% CI 1.11-1.32) vs. 2014-32% (OR 1.32, 95% CI 1.21-1.44)) (p < 0.001). Early discharge was associated with insurance status, diagnosis (benign vs. malignant disease), general health, and overall hospital volume (all p < 0.05). Among patients who had an early discharge, 30- and 90-day readmission was 11.5 and 17.4%, respectively. In contrast, 30- and 90-day readmission was 16.9 and 24.7%, respectively, among patients who had a routine discharge group (p < 0.001). Among patients readmitted within 90 days, in-hospital mortality was similar among patients who had early (n = 43, 2.4%) versus routine discharge (n = 65, 1.9%). Median charges were lower among patients who had an early versus routine versus late discharge ($54,476 [IQR 40,053-79,100] vs. $75,192 [IQR 53,296-113,123] vs. $115,061 [IQR 79,162-171,077], respectively) (p < 0.001).

CONCLUSIONS

Early discharge after HPB surgery was not associated with increased 30- or 90-day readmission. Overall 90-day in-hospital mortality following a readmission was comparable among patients with an early, routine, and late discharge, while median charges were lower in the early discharge group.

Temporal Trends and Clinical Consequences of Wait Times for Transcatheter Aortic Valve Replacement

Background:

Transcatheter aortic valve replacement (TAVR) represents a paradigm shift in the therapeutic options for patients with severe aortic stenosis. However, rapid and exponential growth in TAVR demand may overwhelm capacity, translating to inadequate access and prolonged wait times. Our objective was to evaluate temporal trends in TAVR wait times and the associated clinical consequences.

Methods:

In this population-based study in Ontario, Canada, we identified all TAVR referrals from April 1, 2010, to March 31, 2016. The primary outcome was the median total wait time from referral to procedure. Piecewise regression analyses were performed to assess temporal trends in TAVR wait times, before and after provincial reimbursement in September 2012. Clinical outcomes included all-cause death and heart failure hospitalizations while on the wait list.

Results:

The study cohort included 4461 referrals, of which 50% led to a TAVR, 39% were off-listed for other reasons, and 11% remained on the wait list at the conclusion of the study. For patients who underwent a TAVR, the estimated median wait time in the postreimbursement period stabilized at 80 days and has remained unchanged. The cumulative probability of wait-list mortality and heart failure hospitalization at 80 days was ≈2% and 12%, respectively, with a relatively constant increase in events with increased wait times.

Conclusions:

Postreimbursement wait time has remained unchanged for patients undergoing a TAVR procedure, suggesting the increase in capacity has kept pace with the increase in demand. The current wait time of almost 3 months is associated with important morbidity and mortality, suggesting a need for greater capacity and access.