title: Successful fast track protocol implementation for patients undergoing transapical transcatheter aortic valve implantation.
abstract: BACKGROUND
  The aim of the current study is to report our experience with fast-track treatment of patients undergoing transapical transcatheter aortic valve implantation (TA-TAVI) and to determine perioperative predictors for fast-track protocol failure.
  
  
  METHODS
  Being one of the pioneering centers to start performing TA-TAVI back in 2005, we routinely included patients undergoing this procedure into our fast-track management program since 2008. Between January 2008 and June 2013, 207 consecutive high-risk patients (mean age 79 ± 7 years, mean Log. EuroSCORE 24 ± 10) who underwent TA-TAVI accordingly to our institutional fast-track approach were prospectively collected and analyzed. Uni- and multivariate analysis were performed to identify independent pre- and perioperative predictors of fast-track protocol failure, defined as inability to discharge the patient from the intensive care unit (ICU) on the day of surgery or as readmission to the ICU 48 h after the initial discharge.
  
  
  RESULTS
  Fast-track management was successful in 83 % of the patients. 30-day mortality was 8 %. Fast-track protocol failure (17 %) was associated with an outcome worsening compared to the remaining patients (mortality: 40 % vs. 2 % and mean hospital stay: 19 ± 12 vs. 10 ± 9 days; P = .002). Independent predictors of fast-track protocol failure were age ≥85 years (OR 3.1; CI 95 % 1.89-6.21), ejection fraction (EF) ≤30 % (OR 2.6; CI 95 % 1.99-7.52), moderate to severe preoperative mitral valve regurgitation (OR 2.7; CI 95 % 1.27-6.43) and fluoroscopy time ≥12 min (OR 2.9; CI 95 % 1.28-7.46).
  
  
  CONCLUSIONS
  Fast-track patient management following TA-TAVI is safe and reproducible in the majority of patients. Besides patient-related preoperative risk factors (age ≥85 years, EF ≤30 % and moderate to severe preoperative mitral valve regurgitation) a technically challenging intraoperative course as evidenced in a prolonged fluoroscopy time are independent predictors of fast-track protocol failure which is associated with high loss of patient outcome.
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany. nestoras.papadopoulos@gmail.com.
authors.forename: Nestoras
authors.initials: N
authors.lastname: Papadopoulos
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany.
authors.forename: Ali
authors.initials: A
authors.lastname: El-Sayed Ahmad
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany.
authors.forename: Marlene
authors.initials: M
authors.lastname: Thudt
authors.affiliation: Division of Cardiology, Johann-Wolfgang-Goethe University Frankfurt/Main, Frankfurt, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Fichtlscherer
authors.affiliation: Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Hospital Frankfurt/Main, Frankfurt, Germany.
authors.forename: Patrick
authors.initials: P
authors.lastname: Meybohm
authors.affiliation: Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Hospital Frankfurt/Main, Frankfurt, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Reyher
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany.
authors.forename: Anton
authors.initials: A
authors.lastname: Moritz
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Zierer
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002985:Clinical Protocols; D005260:Female; D005471:Fluoroscopy; D005858:Germany; D006302:Health Services Research / Q000379:methods; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008944:Mitral Valve Insufficiency / Q000150:complications; D011182:Postoperative Care / Q000379:methods*; D012307:Risk Factors; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*; D016896:Treatment Outcome
keywords: Cardiac catheterization/intervention; Heart valve prosthesis (bioprosthetic); Heart valve replacement; Percutaneous; Transapical