Risk Stratification and Clinical Pathways to Optimize Length of Stay After Transcatheter Aortic Valve Replacement
Risk Stratification and Clinical Pathways to Optimize Length of Stay After Transcatheter Aortic Valve Replacement
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DOI：
10.1016/j.cjca.2014.07.012
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发表时间：
2014-12-01
影响因子：
6.2
通讯作者：
Webb, John G.
中科院分区：
文献类型：
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作者：
Lauck, Sandra B.;Wood, David A.;Webb, John G.
背景：经导管主动脉瓣置换术（TAVR）项目的经验和进展为引入极简临床途径提供了机会。本研究的目的是确定全麻和经食管超声心动图（GA/TEE）或清醒TAVR的术前个体化风险分层以及术后标准或快速出院TAVR临床途径的安全性和可行性。方法：采用标准化筛查和多学科心脏科团队共识来评估个体围手术期风险和需求。术后临床状态和标准指导出院时间。我们根据术中实践和术后轨迹评估标准化TAVR结果和住院时间。结果：在2013年连续144例接受TAVR的患者中（平均年龄82.0 +/- 7.1岁，38.2%为女性，胸外科学会平均评分6.5% +/- 4.1%），101例（69.1%）被分配到GA/TEE方案，43例（29.9%）被分配到极简清醒TAVR方案。不论麻醉方式如何，94例（65.3%）患者在标准时间内出院，50例（34.7%）患者适合快速出院。30天的总体结果为2.1%死亡率，1.4%卒中和2.1%危及生命的出血。清醒TAVR组（2天，四分位间距[IQR]， 1-3天）和快速出院组（2天，IQR， 1-2天）的中位住院时间最短，GA/TEE和标准出院组（3天，IQR， 3-4天）的中位住院时间更长。结论：通过个体化风险分层选择最佳围手术期实践和确定出院时间，可获得良好的预后和缩短住院时间。这些发现应在大型长期临床研究中进一步评估。
Background: Transcatheter aortic valve replacement (TAVR) program experience and advances present opportunities to introduce minimalist clinical pathways. The purpose of this study was to determine the safety and feasibility of preprocedural individualized risk stratification for general anaesthesia and transesophageal echocardiography (GA/TEE) or awake TAVR and the postprocedural standard or rapid discharge TAVR clinical pathways.Methods: Standardized screening and multidisciplinary heart team consensus was used to evaluate individual periprocedural risk and requirements. Postprocedural clinical status and criteria guided the timing of discharge. We evaluated standardized TAVR outcomes and length of stay according to periprocedural practice and postprocedural trajectory.Results: In 144 consecutive patients who underwent TAVR in 2013 (mean age, 82.0 +/- 7.1 years; 38.2% women; mean Society of Thoracic Surgeons score, 6.5% +/- 4.1%), 101 (69.1%) were assigned to the GA/TEE protocol, whereas 43 (29.9%) were assigned to the minimalist awake TAVR protocol. Irrespective of mode of anaesthesia, 94 (65.3%) patients were discharged within the standard time, whereas 50 (34.7%) patients were suitable for rapid discharge. Overall outcomes at 30 days were 2.1% mortality, 1.4% stroke, and 2.1% life-threatening bleeding. Median length of stay was shortest in the awake TAVR group (2 days; interquartile range [IQR], 1-3 days) and rapid discharge group (2 days; IQR, 1-2 days) and longer in the GA/TEE and standard discharge (3 days, IQR, 3-4 days) groups.Conclusions: Excellent outcomes and decreased length of stay can be achieved with individualized risk stratification to select the optimal periprocedural practice and determine the timing of discharge. These findings should be further evaluated in a large long-term clinical study.