What is the clinical evidence from this study?

Study design: Cohort. Population: Severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) (n=809). Intervention: Conscious sedation vs. General anesthesia. Primary outcome: Length of stay post-TAVR procedure (HR 1.19, 95% CI 1.06-1.35, p=0.004).

May 26, 2017Open Access

Factors associated with length of stay following trans-catheter aortic valve replacement - a multicenter study

Key Result

Conscious sedation was associated with a significantly shorter length of stay following transcatheter aortic valve replacement compared to general anesthesia (HR 1.19).

Study Design

Type

Cohort (n=809)

Multicenter

Yes

Structured PICO

What patient and procedural factors are associated with length of stay following transcatheter aortic valve replacement?

Population

809 patients undergoing transcatheter aortic valve replacement (TAVR) from January 2012 to December 2014 at three tertiary institutions, mean age 82.7, 51.3% female.

Intervention

Transcatheter aortic valve replacement (TAVR) with various access routes, valve types, and anesthesia strategies.

Outcome

Length of stay (LOS) post-TAVR procedure

Modifiable procedural factors such as the use of conscious sedation and avoiding transapical access are associated with shorter length of stay following TAVR.

Main Result

Effect estimate: HR 1.19 (95% CI 1.06-1.35)

p-value: p=0.004

Limitations

Limited to three tertiary care hospitals with wide variability in clinical practice, impacting generalizability.
Observational study design means there may be residual confounders not accounted for.
Lack of data on frailty or social status.
Small number of cases for certain valve types and access routes, making conclusions susceptible to learning curve effects.
Identifying associated factors does not guarantee that modifying them will empirically translate to shorter length of stay.

Abstract

BACKGROUND: Most patients undergoing Transcatheter aortic valve implantation (TAVR) are elderly with significant co-morbidities and there is limited information available regarding factors that influence length of stay (LOS) post-procedure. The aim of this study was to identify the patient, and procedural factors that affect post-TAVR LOS using a contemporary multinational registry. METHODS: We conducted a retrospective cohort study, with patients recruited from three high volume tertiary institutions. The primary outcome was the LOS post-TAVR procedure. We examined patient and procedural factors in a cause-specific Cox multivariable regression model to elucidate their effect on LOS, accounting for the competing risk of post-procedural death. Hazard ratios (HR) greater than 1 indicate a shorter LOS, while HRs less than 1 indicate a longer LOS. RESULTS: The cohort consisted of 809 patients. Patient factors associated with longer LOS were older age, prior atrial fibrillation, and greater patient urgency. Patient factors associated with shorter LOS were lower NYHA class, higher ejection fraction and higher mean aortic valve gradients. Procedural characteristics associated with shorter LOS were conscious sedation (HR = 1.19, 95% CI 1.06-1.35, p = 0.004). Transapical access was associated with prolonged LOS (HR = 0.49, 95% CI 0.41-0.58, p < 0.001). CONCLUSION: This multicenter study identified potentially modifiable patient and procedural factors associated with a prolonged LOS. Future research is needed to determine if interventions focused on these factors will translate to a shorter LOS.

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