title: Risk stratification and clinical pathways to optimize length of stay after transcatheter aortic valve replacement.
abstract: BACKGROUND
  Transcatheter aortic valve replacement (TAVR) program experience and advances present opportunities to introduce minimalist clinical pathways. The purpose of this study was to determine the safety and feasibility of preprocedural individualized risk stratification for general anaesthesia and transesophageal echocardiography (GA/TEE) or awake TAVR and the postprocedural standard or rapid discharge TAVR clinical pathways.
  
  
  METHODS
  Standardized screening and multidisciplinary heart team consensus was used to evaluate individual periprocedural risk and requirements. Postprocedural clinical status and criteria guided the timing of discharge. We evaluated standardized TAVR outcomes and length of stay according to periprocedural practice and postprocedural trajectory.
  
  
  RESULTS
  In 144 consecutive patients who underwent TAVR in 2013 (mean age, 82.0 ± 7.1 years; 38.2% women; mean Society of Thoracic Surgeons score, 6.5% ± 4.1%), 101 (69.1%) were assigned to the GA/TEE protocol, whereas 43 (29.9%) were assigned to the minimalist awake TAVR protocol. Irrespective of mode of anaesthesia, 94 (65.3%) patients were discharged within the standard time, whereas 50 (34.7%) patients were suitable for rapid discharge. Overall outcomes at 30 days were 2.1% mortality, 1.4% stroke, and 2.1% life-threatening bleeding. Median length of stay was shortest in the awake TAVR group (2 days; interquartile range [IQR], 1-3 days) and rapid discharge group (2 days; IQR, 1-2 days) and longer in the GA/TEE and standard discharge (3 days, IQR, 3-4 days) groups.
  
  
  CONCLUSIONS
  Excellent outcomes and decreased length of stay can be achieved with individualized risk stratification to select the optimal periprocedural practice and determine the timing of discharge. These findings should be further evaluated in a large long-term clinical study.
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada. Electronic address: slauck@providencehealthcare.bc.ca.
authors.forename: Sandra B
authors.initials: SB
authors.lastname: Lauck
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: David A
authors.initials: DA
authors.lastname: Wood
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada.
authors.forename: Leslie
authors.initials: L
authors.lastname: Achtem
authors.affiliation: University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Baumbusch
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Boone
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Anson
authors.initials: A
authors.lastname: Cheung
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada.
authors.forename: Danny
authors.initials: D
authors.lastname: Dvir
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada.
authors.forename: Dion
authors.initials: D
authors.lastname: Stub
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada.
authors.forename: John S
authors.initials: JS
authors.lastname: Tan
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Jian
authors.initials: J
authors.lastname: Ye
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: John G
authors.initials: JG
authors.lastname: Webb
mesh_terms: D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001955:British Columbia / Q000453:epidemiology; D006328:Cardiac Catheterization; D019091:Critical Pathways; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay / Q000639:trends*; D008297:Male; D018570:Risk Assessment / Q000379:methods*; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*; D016896:Treatment Outcome