Going Home the Same Day After a Heart Valve Replacement? A Review of How We Care for Patients After TAVR

Podcast Transcript

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Samir Kapadia, MD:

Hello everybody. I'm Samir Kapadia, Chairman of Cardiology here at Cleveland Clinic, and with me today we have Amar Krishnaswamy, who is the Director of the Cath Lab at Cleveland Clinic and also the Head of the Interventional Section at Cleveland Clinic. And we are trying to go over this huge accomplishment we have, not just as we at Cleveland Clinic, but in general, in the field of TAVR, to say that how we discharge the patient on the same day. So just to put it in perspective, when we started in 2006, we did our first TAVR, we not only kept the patient in the hospital, but they were in the hospital for more than a week. A very large tube went in the patients, these patients were monitored very closely for a long time. And in the first six years or so, we did 250 to 260 patients. So now every year we are doing close to 700 patients, 650 to 700 patients a year. And Dr. Krishnaswamy and all of us have led this effort to discharge the patient the same day.

So, Amar, I want to find out from you to say what are the things that are so different or what are the things that happen that is allowing us to even consider discharging a patient after aortic valve replacement, a valve replacement, to home?

Amar Krishnaswamy, MD:

Thanks, Dr. Kapadia. I think first we should just kind of lay the groundwork or lay the foundation for why it is important for patients to leave the hospital sooner. So, if we look at any of the catheter-based interventions we've been doing for coronary disease, peripheral artery disease, structural heart disease, over time, the length of stay, as we've done more procedures, as we've understood more what the follow-up for these procedures is, the length of stay has consistently declined. So, for example, if you look even a few years ago, the average length of stay after TAVR was three days or more nationally, and a major paper came out saying that discharging patients within three days is safe.

So, we're not doing anything so drastic, we're simply understanding the data better to move the field along by saying same day discharge is safe. And in that regard, in the most recent year, 2022, almost 40 to 45 percent of our patients were discharged on the same day that they came in for a TAVR. It's actually quite similar to what we do in coronary intervention, in the most recent year, almost 60 percent of our patients who had a coronary stent were discharged in the same day. So, I think just for patients and other providers and operators to understand, I think what we're doing is very consistent with the safety of the data that exists, and it's not something that's so far off the map that most sites can't also accomplish in their own programs.

So, the things that have really allowed us to pursue a shorter and shorter length of stay in the hospital is that overall, the procedures are becoming safer, the devices themselves are becoming more consistent to use, and the operator experience that we have to analyze the patients and do the cases is all getting safer. The catheters that we use are smaller, so the risks of a complication in the vascular bed is less. The ways in which we have learned to implant the valve to reduce the risk of a pacemaker has really allowed us to reduce the pacemaker rate from almost 10 percent nationally to about 2.5 to 3 percent in our institution. So that's also an important point that allows us to discharge patients sooner because the length of time they have to stay for rhythm monitoring is less.

Samir Kapadia, MD:

Now, do you think that the patients like it, to go home or what is the perception of the patients? Because ultimately we do this for the convenience of the patients and the families because we think at least the patients, at least in my opinion, the patients like it that they sleep in their own bed, they're not confused, they can go to the bathroom in their home, take shower and come back next day for a visit, a clinic visit. So, this is a huge satisfaction in my mind, but what do you think of your patients, do they feel that it is much better to go home the same day, or they don't mind staying in the hospital one or two days?

Amar Krishnaswamy, MD:

I think it's very much patient and family centered, as in everything that we try to do. I think it's important for the patients and the families to understand what the benefits are of being out of the hospital. I think there's a large amount of literature, not just in TAVR, but in most things, that staying in the hospital for a longer period of time can hurt, whether it's in infections in the hospital, whether it's a risk of delirium in the hospital, which is especially significant for older or elderly patients in the TAVR group. So, these are the potential benefits outside of just convenience and the happiness or enjoyment of being at home that a same day discharge can really provide.

Once patients and families understand that they see that there are a lot of potential benefits to leaving sooner, but that does imply both the comfort that the patient and the family has to leave the hospital and also that they have an infrastructure of support outside of the hospital. In our study that we published, 95 percent of the patients went back to their own home, and so they had a situation at home where they could be watched over by a family member or a caregiver so that they weren't worried that they were on their own.

Samir Kapadia, MD:

No, wonderful. And what are the most important criteria? I think the most important fact that we can discharge 40 percent of patients is the fact that they have no complications. So first and foremost, a procedure has to be safe, and we are monitoring the patients, monitoring our outcomes. We have not seen any ill effects from this same day discharge. But what are the most important features that are needed to make this program successful?

Amar Krishnaswamy, MD:

Sure. So we have a solid infrastructure, not only of operators doing the procedure, but the nursing teams that are taking care of the patients at the bedside, the advanced practitioners, the nurse practitioners and physician assistants that follow up on the patients after the procedures to analyze the access sites, to analyze the heart rhythm, telemetries and ECGs, to look at the echocardiograms, to make sure that there's nothing at all of concern that would require a longer stay in the hospital for observation. If we can check all of those boxes and feel confident in this regard, we still make sure that the patient, once their bedrest period is completed, they can walk around the hallways comfortably without too much pain, without sort of disability in that regard. And then we have a final check with the patient and their family to see that they're okay and they're comfortable with the idea of going back home on the same day.

Samir Kapadia, MD:

No, that's wonderful. I think the most important thing is the patient and family has to feel comfortable, along with us to say that it is safe. But this has really revolutionized. I know that you said that a lot of people can potentially do it, but really speaking, how common do you think the same day discharge is in the world or for that matter, in United States?

Amar Krishnaswamy, MD:

Yeah, it's an important point you say the world versus United States, because in fact, outside of the US the length of stay in TAVR is often the better part of a week. In fact, in a recent European conference, a major late-breaking clinical trial showed that it was okay to discharge patients I think within four or five days. This was the major finding that they reported. And so, I think in this regard, we are actually quite advanced in the US to say that on average the length of stay after TAVR in the US is between one and two days.

Samir Kapadia, MD:

But very few academic centers discharge the same day. They usually keep them overnight.

Amar Krishnaswamy, MD:

And especially when we present our Cleveland Clinic data in major national, international conferences, people are really fascinated by this data because I think there's a lot of interest for the benefit of the patients and also frankly for the benefit of the hospital systems to allow them to take care of more patients, to have a shorter discharge. So, when they look at how we have studied our outcomes and to look at the criteria that we have used to say that almost 40 percent of our patients can go home in the same day, I think a lot of institutions are interested in pursuing a similar discharge pathway.

Samir Kapadia, MD:

No, that's wonderful. So again, for the patients, what is the most important message that they want to give to the patients, that what is the same day discharge mean? That is one, in my mind, is that the procedure is simple. Second, is it's safe. Third is that in an experienced center, the rate of complication is so low that patients can go home the same day, and this is a huge accomplishment. But I personally also want to state and maybe learn from you to say that is it possible in a less experienced center and with less infrastructure, because we don't want to create a problem with the systems and make the unsafe recommendation to other institutions where this is probably going to be a problem.

Amar Krishnaswamy, MD:

I think there are two very important points to the question you asked. One is how generalizable is this among centers, and the second is to specifically discuss the infrastructure that it requires. We know from plenty of data that there's great variability in results of TAVR, whether it's things like stroke and mortality or whether it's pacemaker rates across the nation. And so, I think for a given institution to consider an early discharge pathway, they really need to understand their own data. If they have higher rates of pacemaker implantation, that might not be a great situation for worry of kind of delayed pacemaker complications, for example.

The other part of it is that we're fortunate to have an infrastructure of nurses and advanced practice providers that not only see the patients after the procedures, along, of course, with our fellows that work with us, but then on the next day after the discharge, they have an appointment with the advanced practice provider. They have a clinical assessment, a lab testing assessment, and they have an ECG assessment. So, this next day is a very important appointment, and so systems really need to have that in place to feel confident about discharging patients on the same day.

Samir Kapadia, MD:

No, outstanding. Thank you very much again for the great discussion.

Amar Krishnaswamy, MD:

Thanks, Dr. Kapadia.

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