title: Rationale, development, implementation, and initial results of a fast track protocol for transfemoral transcatheter aortic valve replacement (TAVR).
abstract: BACKGROUND
  The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particularly in the US, was initially based on open surgical techniques and often includes general anesthesia, transesophageal echocardiographic monitoring, and cardiothoracic intensive care unit (ICU) stays. Whether a subgroup of patients could benefit from early extubation, fewer days in the ICU, and early ambulation in terms of both cost and effectiveness is unknown.
  
  
  RESULTS
  A fast track (FT) protocol was initiated at two institutions in our health system with specific inclusion criteria. Patients with complications or morbidity post procedure deemed ineligible to continue on the FT pathway were designated as deviations. Baseline characteristics, success and deviations, subsequent course, and direct costs were compared for FT eligible and ineligible patients over a 6-month study period. Among 99 patients undergoing Transfemoral TAVR, 39 (39%) met FT inclusion criteria. The mean age of eligible and ineligible patients was similar at 85 years, but by design, eligible patients had fewer co-morbid conditions. Successful completion of the FT protocol was achieved in 28 patients (72%). Patients on the FT had shorter ICU stays (28 ± 103 vs 45 ± 46 hours, P < 0.0001) and post-operative length of stay (4.3 ± 4.4 vs 7.2 ± 5.3 days, P < 0.0001), and incurred lower direct costs ($44,923 ± $14,187 vs $56, 339 ± 17,808, P < 0.0001).
  
  
  CONCLUSIONS
  It is feasible to identify a large percentage of suitable patients preprocedure who are eligible for a FT postprocedure care pathway. There was no evidence for compromise of care and successful completion of the pathway was associated with shorter length of stay and fewer direct costs.
authors.affiliation: University of Pennsylvania Health System and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Marcantuono
authors.forename: Jacob
authors.initials: J
authors.lastname: Gutsche
authors.forename: Maureen
authors.initials: M
authors.lastname: Burke-Julien
authors.forename: Saif
authors.initials: S
authors.lastname: Anwaruddin
authors.forename: John G
authors.initials: JG
authors.lastname: Augoustides
authors.forename: David
authors.initials: D
authors.lastname: Jones
authors.forename: Lisa
authors.initials: L
authors.lastname: Mangino-Blanchard
authors.forename: Nicole
authors.initials: N
authors.lastname: Hoke
authors.forename: Stephanie
authors.initials: S
authors.lastname: Houseman
authors.forename: Robert
authors.initials: R
authors.lastname: Li
authors.forename: Prakash
authors.initials: P
authors.lastname: Patel
authors.forename: Robert
authors.initials: R
authors.lastname: Stetson
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Walsh
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.forename: Howard C
authors.initials: HC
authors.lastname: Herrmann
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D002985:Clinical Protocols; D015897:Comorbidity; D017046:Cost Savings; D005240:Feasibility Studies; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay; D008297:Male; D018579:Patient Selection; D015143:Philadelphia; D016730:Program Development; D015397:Program Evaluation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: aortic stenosis; transcatheter aortic valve replacement