Improved Outcomes in Transcatheter Aortic Valve Replacement using a Minimalist Approach: A Single Center Experience
Kendra J. Grubb, Tyler Fields, Mary Jo Noon, Michael Flaherty, Jaimin Trivedi.
University of Louisville, Louisville, KY, USA.
OBJECTIVE: Transcatheter aortic valve replacement (TAVR) has transformed the management of aortic stenosis (AS). A minimalist approach (MA) to TAVR, relying on local anesthesia and conscious sedation (MAC) has been utilized and has a reported benefit of improved outcomes.
METHODS: A single center, prospective, study of 50 consecutive MA-TAVR patients compared to 50 patients who underwent TAVR under general anesthesia (GA-TAVR). The MA-TAVR protocol included intraoperative MAC and transthoracic echocardiogram guidance, and a postoperative protocol including no narcotics, mobilization within 4 hours of ICU arrival, and the goal of discharge directly from the ICU postoperative day 1. Patients were treated with balloon expandable or self-expanding valves. Preoperative, intraoperative, and postoperative data was collected.
RESULTS: Fifty consecutive patients with appropriate anatomy for a percutaneous approach were assigned to the MA-TAVR protocol. Preoperative variables and comorbidities were not significantly different between the MA-TAVR and GA-TAVR cohorts, with the exception of fewer females undergoing MA-TAVR (26% (13) vs 56% (28), p=0.002) and higher STS PROM (10.7+/- 3.3 vs 9.1+/-5.5, p=0.002) in the MA-TAVR group. Intraoperative variables were similar with the exception of a lower volume of contrast utilized during the MA-TAVR (126.9mL vs 207.7mL, p<0.0001). Postoperatively, there was no difference in in-hospital mortality, mortality at 30 days, major vascular complication, need for permanent pacemaker, or stroke. There was a clinical increase in the number of patients who developed renal failure and required dialysis in the GA-TAVR group (6% (3) vs 0 in MA-TAVR, p=0.07). A higher proportion of MA-TAVR patients were discharged to home (78% (39) vs 58% (29), p=0.05) with a significantly shorter postoperative length of stay (2.5+/-3.3 (median 1) vs 5.1+/-3.8 (median 4) days, p<0.0001).
CONCLUSIONS: MA-TAVR is safe and associated with low morbidity and mortality. Implementation of a MA-TAVR protocol resulted in shorter length of hospitalization with the majority of patients discharged to home. The improved outcomes associated with MA-TAVR illustrate increased efficiency and potential cost savings.
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