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A standardized, risk-stratified approach to transfemoral transcatheter aortic valve replacement (TAVR) may be useful for shortening lengths of stay, researchers suggested.

In an article describing how one hospital went from early adopter with a cautious approach to stay duration to an experienced center with a risk-stratified approach aimed at getting patients home as soon as safe, , of St. Paul's Hospital in Vancouver, and colleagues presented a pathway for efficiency.

"As evidence emerges that TAVR is an effective therapy for intermediate surgical risk patients, the implementation of a risk-stratified clinical pathway will garner increased importance. TAVR programs will experience new pressures to increase capacity to meet patient need in the future," and colleagues wrote in Circulation: Cardiovascular Quality and Outcomes.

"Until the acquisition costs of devices decrease, the acceptability of TAVR as a reasonable and financially viable alternative to surgery will be driven by the mitigation of expenses related to complications, procedural approaches, and length of stay," they added.

Components of their program, developed in 2012, included immediate transthoracic echocardiography after the procedure, instead of transesophageal echocardiography; local anesthesia, instead of general anesthesia; not using a urinary catheter; and reducing bed rest to 4 to 6 hours, down from 8 hours.

Lauck's group also had patients staying in critical care for less than 24 hours and leaving the center within 1 to 3 days, as opposed to historical expectations of 24 to 48 hours and 3 to 5 days, respectively.

Retrospective analysis of 397 transfemoral TAVR procedures completed during and after implementation, from May 2012 through October 2014, showed:

• 4 (1.0%) post-procedure in-hospital deaths
• 1.7% 30-day mortality
• 38.2% discharged within 48 hours of their procedures
• 16 (4%) required an extended stay of 8 to 22 days
• 10.7% 30-day readmission

Rates of stroke, bleeding, vascular complications, new dialysis, and periprocedural myocardial infarction were low for both early discharge and other patients, the researchers noted.

The authors called these findings a demonstration "that shorter length of stay and excellent outcomes can be achieved by conducting pre-procedure risk stratification planning, shifting to a default practice of local anesthesia, standardizing post-procedure care with early mobilization, and reconditioning."

In conjunction with other North American centers, they are further testing this pathway in the ongoing .

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