The safety of early discharge following transfemoral transcatheter aortic valve replacement under general anesthesia

Ofir Koren; Vivek Patel; Siamak Kohan; Robert Naami; Edmund Naami; Zev Allison; Sharon Shalom Natanzon; Alon Shechter; Takashi Nagasaka; Ahmed Al Badri; Arvind Reddy Devanabanda; Mamoo Nakamura; Wen Cheng; Hasan Jilaihawi; Raj R Makkar

doi:10.3389/fcvm.2022.1022018

The safety of early discharge following transfemoral transcatheter aortic valve replacement under general anesthesia

Front Cardiovasc Med. 2022 Oct 21:9:1022018. doi: 10.3389/fcvm.2022.1022018. eCollection 2022.

Authors

Ofir Koren^{1

2}, Vivek Patel¹, Siamak Kohan³, Robert Naami⁴, Edmund Naami⁵, Zev Allison¹, Sharon Shalom Natanzon¹, Alon Shechter^{1

6}, Takashi Nagasaka^{1

7}, Ahmed Al Badri¹, Arvind Reddy Devanabanda¹, Mamoo Nakamura¹, Wen Cheng¹, Hasan Jilaihawi⁸, Raj R Makkar¹

Affiliations

¹ Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States.
² Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.
³ Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, United States.
⁴ Internal Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
⁵ School of Medicine, University of Illinois Chicago, Chicago, IL, United States.
⁶ Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
⁷ Department of Cardiology, Gunma University Hospital, Gunma, Japan.
⁸ Heart Valve Center, NYU Langone Health, New York City, NY, United States.

Abstract

Background: There is growing evidence of the safety of same-day discharge for low-risk conscious sedated TAVR patients. However, the evidence supporting the safety of early discharge following GA-TAVR with routine transesophageal echocardiography (TEE) is limited.

Aims: To assess the safety of early discharge following transcatheter aortic valve replacement (TAVR) using General Anesthesia (GA-TAVR) and identify predictors for patient selection.

Materials and methods: We used data from 2,447 TEE-guided GA-TAVR patients performed at Cedars-Sinai between 2016 and 2021. Patients were categorized into three groups based on the discharge time from admission: 24 h, 24-48 h, and >48 h. Predictors for 30-day outcomes (cumulative adverse events and death) were validated on a matched cohort of 24 h vs. >24 h using the bootstrap model.

Results: The >48 h group had significantly worse baseline cardiovascular profile, higher surgical risk, low functional status, and higher procedural complications than the 24 h and the 24-48 h groups. The rate of 30-day outcomes was significantly lower in the 24 h than the >48 h but did not differ from the 24-48 h (11.3 vs. 15.5 vs. 11.7%, p = 0.003 and p = 0.71, respectively). Independent poor prognostic factors of 30-day outcomes had a high STS risk of ≥8 (OR 1.90, 95% CI 1.30-2.77, E-value = 3.2, P < 0.001), low left ventricle ejection fraction of <30% (OR 6.0, 95% CI 3.96-9.10, E-value = 11.5, P < 0.001), and life-threatening procedural complications (OR 2.65, 95% CI 1.20-5.89, E-value = 4.7, P = 0.04). Our formulated predictors showed a good discrimination ability for patient selection (AUC: 0.78, 95% CI 0.75-0.81).

Conclusion: Discharge within 24 h following GA-TAVR using TEE is safe for selected patients using our proposed validated predictors.

Keywords: conscious sedation; early discharge; general anesthesia; length of stay; mortality; predictors; safety discharge; transcatheter aortic valve replacement.