Safety of Accelerated Recovery on a Cardiology Ward and Early Discharge Following Minimalist TAVR in the Catheterization Laboratory: The Vancouver Accelerated Recovery Clinical Pathway

ABSTRACT

Background: We assessed the safety and efficacy of a clinical pathway with transfemoral transcatheter aortic valve replacement (TAVR) performed in the catheterization laboratory, accelerated recovery on a general cardiology ward and early discharge.

Methods: The Vancouver accelerated recovery clinical pathway is an initiative with aims to implement (1) multidisciplinary team selection of patients with lower TAVR procedural risk; (2) peri-procedural minimalist approach with minimal procedural sedation; (3) pre-specified criteria for accelerated transfer to a general cardiology ward; (4) rapid reconditioning post-procedural care; and (5) identification of patients suitable for early (<48 hours) discharge home.

Results: A total of 100 prospective patients underwent TAVR with the Vancouver accelerated recovery pathway between September 2016 and August 2018 with a mean age of 79.4 ± 7.4 years and Society of Thoracic Surgeons (STS) score of 3.5 ± 1.7 (55% had STS≥3). Only one (1%) patient needed conversion to general anesthesia, two (2%) patients needed urgent pacemaker implantation for conduction disorder, one (1%) patient had a stroke and five (5%) patients had minor vascular complications. All patients were transferred to the ward but one (1%) patient subsequently needed escalation of care to the coronary care unit. Mean time to first mobilization was 267 ± 60 minutes. Overall, 87 (87%) patients achieved next day discharge and 97 (97%) patients were discharged ≤48 hours. The 30-day mortality was 1% and all-cause readmission rate was 5%.

Conclusion: Use of the Vancouver accelerated recovery pathway in highly-selected patients allows TAVR to be performed in the catheterization laboratory followed by accelerated recovery to the ward, with minimal mortality, morbidity, and a high proportion of early discharge. As TAVR continues to expand, this has important implications for health care delivery.

KEYWORDS:

• Transcatheter aortic valve replacement
• aortic stenosis
• minimalist
• clinical pathway
• early discharge
• health services

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Disclosure statement

Dr Blanke is a consultant to Edwards Lifesciences. Dr Lauck is a consultant to Edwards Lifesciences. Dr Webb is a consultant to, and has received research funding from, Edwards Lifesciences, Abbott Vascular, Boston Scientific, and ViVitro Labs. He has received research funding from Edwards Lifesciences. Dr Leipsic is a consultant to Edwards Lifesciences and provides CT core lab services for Edwards Lifesciences, Medtronic, Neovasc, GDS, and Tendyne Holdings, for which no direct compensation is received. Dr Leipsic has stock options in, is a consultant to, and receives institutional research support from HeartFlow and is supported by a Canadian Research Chair in Advanced CardioPulmonary Imaging. Dr Wood is a consultant to, and has received research funding from Edwards Lifesciences.