1
|
Meniconi MA, Oliveira FJC, Cervone AC, Togna DJD, Feres F, Ramos AIDO, Siqueira DADA. Viability and Safety of Early Hospital Discharge after Minimalist TAVI in the Brazilian Unified Health System. Arq Bras Cardiol 2023; 120:e20230328. [PMID: 37878895 PMCID: PMC10547432 DOI: 10.36660/abc.20230328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 10/27/2023] Open
Abstract
Central Illustration : Viability and Safety of Early Hospital Discharge after Minimalist TAVI in the Brazilian Unified Health System Results after transcatheter aortic valve implantation with a minimalist approach. CKD: chronic kidney disease; PO: postoperative days; TAVI: transcatheter aortic valve implantation.
Collapse
Affiliation(s)
- Marcos Almeida Meniconi
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | | | - Alberto Colella Cervone
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Dorival Julio Della Togna
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Fausto Feres
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | | | | |
Collapse
|
2
|
Tagliari AP, Taramasso M. New Practices in Transcatheter Aortic Valve Implantation: How I Do It in 2023. J Clin Med 2023; 12:jcm12041342. [PMID: 36835878 PMCID: PMC9964275 DOI: 10.3390/jcm12041342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/31/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) went through a huge evolution in the last decades. Previously performed under general anesthesia, with transoperative transesophageal echocardiography guidance and using cutdown femoral artery access, the procedure has now evolved into a minimalist approach, with local anesthesia, conscious sedation, and the avoidance of invasive lines becoming the new standards. Here, we discuss the minimalist TAVI approach and how we incorporate it into our current clinical practice.
Collapse
Affiliation(s)
- Ana Paula Tagliari
- Cardiovascular Surgery Department, Hospital São Lucas da PUC-RS, Porto Alegre 90619-900, Brazil
- Cardiovascular Surgery Department, Hospital Mãe de Deus, Porto Alegre 90880-0481, Brazil
- Correspondence: ; Tel.: +55-(51)-33205186
| | - Maurizio Taramasso
- HerzZentrum Hirslanden Zurich, Clinic of Cardiac Surgery, 8008 Zurich, Switzerland
| |
Collapse
|
3
|
Cusin CN, Clark PA, Lauderbach CW, Wyman J. Reducing length of stay for patients undergoing transcatheter aortic valve replacement using a prescreening approach. J Am Assoc Nurse Pract 2022; 34:844-849. [PMID: 35472192 DOI: 10.1097/jxx.0000000000000719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/04/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND As transcatheter aortic valve replacement (TAVR) becomes a preferred treatment option for patients with aortic valve stenosis, and demand for TAVR increases, it is imperative that length of stay (LOS) is reduced while maintaining safety and effectiveness. LOCAL PROBLEM As TAVR procedures have become less invasive and more streamlined, current protocols have not been updated to reflect today's postprocedure requirements. METHODS The next-day discharge (NDD) protocol was established using available literature. A convenience sample was evaluated for NDD protocol inclusion during aortic multidisciplinary team conference using predetermined inclusion and exclusion criteria. Length of stay for NDD protocol participants was compared with LOS from a retrospective convenience sample of patients undergoing TAVR in the time frame mirroring NDD protocol initiation of the year prior. INTERVENTIONS Patients meeting inclusion criteria were enrolled in the NDD protocol with a goal of discharge to home on postprocedural day 1 by 2:00 p.m. The NDD protocol included preprocedure expectation setting, prescheduled same-day postprocedure imaging, and discharge priority on postprocedure day 1. RESULTS There is a significant difference in LOS between the NDD eligible retrospective and prospective groups. The prospective group has a significantly lower LOS than the retrospective group (M = 1.6 vs 2.1, respectively; p = .0454). CONCLUSIONS An NDD protocol can help reduce LOS after TAVR in appropriately selected patients. Further protocol revision will be required to optimize LOS outcomes.
Collapse
|
4
|
Kratochvílová L, Mašek P, Neuberg M, Nováčková M, Toušek P, Sulženko J, Buděšínský T, Kočka ,AV. OUP accepted manuscript. Eur Heart J Suppl 2022; 24:B28-B35. [PMID: 35370505 PMCID: PMC8971733 DOI: 10.1093/eurheartjsupp/suac009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) varies considerably in terms of the procedural approach taken and the hospital length of stay (LoS); both directly affect the cost of care. Our coronary and standard cardiology unit aimed to simplify TAVI (and thus shorten the LoS) while maintaining safety. A shorter LoS would also reduce the burden on hospital resources and free up beds for other patients. Data on 214 consecutive patients undergoing TAVI at a single centre between April 2018 and March 2021 were retrospectively collected. A simplified protocol was implemented in January 2020; patients were stratified by whether they underwent TAVI before or after simplification. All procedural phases were simplified. For cost comparison purposes, the LoS was defined as the number of hospitalization days from admission to discharge. The total hospitalization cost was the sum of the direct and indirect (including reallocated overhead) costs. The LoS fell significantly (by 36%) after TAVI simplification. The times in the coronary care unit (CCU) and standard cardiac unit (SCU) also fell significantly (by 33% and 37% respectively). Patients in the simplified TAVI group were discharged, on average, 6 days after admission. The CCU costs decreased by 31% and the SCU costs by 39%. Transcatheter aortic valve implantation simplification did not compromise safety. Indeed, patients who underwent the simplified procedure seemed to develop fewer complications, especially bleeding. Transcatheter aortic valve implantation simplification significantly reduced the LoS and other costs without compromising patient safety.
Collapse
Affiliation(s)
- Lenka Kratochvílová
- Medtronic Czechia, Partner in the INTERCARDIS Project, Prosecká 66, Prague 19000, Czech Republic
| | - Petr Mašek
- Medtronic Czechia, Partner in the INTERCARDIS Project, Prosecká 66, Prague 19000, Czech Republic
| | - Marek Neuberg
- Medtronic Czechia, Partner in the INTERCARDIS Project, Prosecká 66, Prague 19000, Czech Republic
| | - Markéta Nováčková
- Department of Cardiology, University Hospital Královské Vinohrady and Third Faculty of Medicine, Charles University, Šrobárova 50, Prague 10, 100 34, Czech Republic
| | - Petr Toušek
- Department of Cardiology, University Hospital Královské Vinohrady and Third Faculty of Medicine, Charles University, Šrobárova 50, Prague 10, 100 34, Czech Republic
| | - Jakub Sulženko
- Department of Cardiology, University Hospital Královské Vinohrady and Third Faculty of Medicine, Charles University, Šrobárova 50, Prague 10, 100 34, Czech Republic
| | - Tomáš Buděšínský
- Department of Cardiology, University Hospital Královské Vinohrady and Third Faculty of Medicine, Charles University, Šrobárova 50, Prague 10, 100 34, Czech Republic
| | - , and Viktor Kočka
- Department of Cardiology, University Hospital Královské Vinohrady and Third Faculty of Medicine, Charles University, Šrobárova 50, Prague 10, 100 34, Czech Republic
- Corresponding author. Tel: +420 267 162 701,
| |
Collapse
|
5
|
Perpetua EM, Guibone KA, Keegan PA, Palmer R, Speight MK, Jagnic K, Michaels J, Nguyen RA, Pickett ES, Ramsey D, Schnell SJ, Wong SC, Reisman M. Best Practice Recommendations for Optimizing Care in Structural Heart Programs: Planning Efficient and Resource Leveraging Systems (PEARLS). STRUCTURAL HEART 2021; 5:168-179. [PMID: 35378800 PMCID: PMC8968322 DOI: 10.1080/24748706.2021.1877858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/11/2021] [Accepted: 09/26/2021] [Indexed: 11/24/2022]
Abstract
The COVID19 pandemic brought unprecedented disruption to healthcare. Staggering morbidity, mortality, and economic losses prompted the review and refinement of care for structural heart disease (SHD). To mitigate negative impacts in the face of crisis or capacity constraints, this paper offers best practice recommendations for Planning Efficient and Resource Leveraging Systems (PEARLS) in structural heart programs. A systematic assessment is recommended for hospital capacity, Heart Team roles and functions, and patient and procedural risks associated with increased resource utilization. Strategies, tactics, and pathways are provided for the delivery of patient-centered, efficient and resource-leveraging care from referral to follow-up. Through the optimal use of capacity and resources, paired with dynamic triage, forecasting, and surveillance, Heart Teams may aspire to plan and implement an optimized system of care for SHD. Abbreviations: AS: aortic stenosis; ASD: atrioseptal defect; COVID19: Coronavirus disease 19; LAAO: left atrial appendage occlusion; MI: myocardial infarction; MR: mitral regurgitation; PFO: patent foramen ovale; PVL: paravalvular leak; SHD: structural heart disease; SAVR: surgical aortic valve replacement; SDM: shared decision-making; TAVR: transcatheter aortic valve replacement; TMVr: transcatheter mitral valve repair; TMVR: transcatheter mitral valve replacement; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography.
Collapse
|
6
|
One-Year Costs Associated with Hospitalizations Due to Aortic Stenosis in Canada. CJC Open 2021; 3:82-90. [PMID: 33474547 PMCID: PMC7801225 DOI: 10.1016/j.cjco.2020.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/15/2020] [Indexed: 12/18/2022] Open
Abstract
Background There is a lack of data on the burden of patients hospitalized with aortic stenosis (AS) in Canada. The primary study objective was to document the index and 1-year costs of hospitalized patients with AS in Canada. Secondary objectives were to explore results by treatment modality and Canadian provinces. Methods Hospitalized patients with a most responsible diagnosis (MRD) of AS during fiscal year 2014/2015 were identified using Canadian administrative databases. Costs were calculated for the index admission and for up to 1 year. For our secondary analyses, patients were classified according to the intervention received: surgical aortic valve replacement (SAVR), SAVR with coronary artery bypass graft, or transfemoral or transapical transcatheter aortic valve implantation. Hospitalized AS patients who did not undergo SAVR or transcatheter aortic valve implantation were classified as the untreated group. The data were also analyzed by Canadian provinces. Results During fiscal year 2014/15, a total of 7217 Canadians were hospitalized with an MRD of AS. The mean (standard deviation) age of our population was 74.2 (11.5) years, and 39% were female. The 1-year hospital costs associated with an MRD of AS in Canada were calculated at $393 million. Our secondary analyses suggest that patient demographics (mean age ranging from 69 to 82 years) and outcomes (median length of stay ranging from 6 to 12 days) differ among treatment modalities and Canadian provinces. Conclusions AS hospitalizations result in a significant cost burden in Canada. Future research is needed to better understand variation among treatment modalities and Canadian provinces.
Collapse
|
7
|
Neuburger PJ, Rong LQ. The Economics of Transcatheter Aortic Valve Replacement and the Anesthesiologist. J Cardiothorac Vasc Anesth 2020; 35:446-448. [PMID: 33353587 DOI: 10.1053/j.jvca.2020.09.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Peter J Neuburger
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine New York, NY
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine New York, NY
| |
Collapse
|
8
|
Lauck S, Forman J, Borregaard B, Sathananthan J, Achtem L, McCalmont G, Muir D, Hawkey MC, Smith A, Højberg Kirk B, Wood DA, Webb JG. Facilitating transcatheter aortic valve implantation in the era of COVID-19: Recommendations for programmes. Eur J Cardiovasc Nurs 2020; 19:537-544. [PMID: 32498556 PMCID: PMC7717283 DOI: 10.1177/1474515120934057] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The COVID-19 pandemic continues to significantly impact the treatment of people living with aortic stenosis, and access to transcatheter aortic valve implantation. Transcatheter aortic valve implantation (TAVI) programmes require unique coordinated processes that are currently experiencing multiple disruptions and are guided by rapidly evolving protocols. We present a series of recommendations for TAVI programmes to adapt to the new demands, based on recent evidence and the international expertise of nurse leaders and collaborators in this field. Although recommended in most guidelines, the uptake of the role of the TAVI programme nurse is uneven across international regions. COVID-19 is further highlighting why a nurse-led central point of coordination and communication is a vital asset for patients and programmes. We propose an alternative streamlined evaluation pathway to minimize patients' pre-procedure exposure to the hospital environment while ensuring appropriate treatment decision and shared decision-making. The competing demands created by COVID-19 require vigilant wait list management, with risk stratification, telephone surveillance and optimized triage and prioritization. A minimalist approach with close scrutiny of all parts of the procedure has become an imperative to avoid any complications and ensure patients' accelerated recovery. Lastly, we outline a nurse-led protocol of rapid mobilization and reconditioning as an effective strategy to facilitate safe next-day discharge home. As the pandemic abates, TAVI programmes must facilitate access to care without compromising patient safety, enable hospitals to manage the competing demands created by COVID-19 and establish new processes to support patients living with valvular heart disease.
Collapse
Affiliation(s)
- Sandra Lauck
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver Canada
| | - Jacqueline Forman
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver Canada
| | - Britt Borregaard
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark
| | - Janarthanan Sathananthan
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver Canada
| | - Leslie Achtem
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver Canada
| | | | - Douglas Muir
- James Cook University Hospital, Middlesbrough, UK
| | | | - Amanda Smith
- Hamilton Health Sciences Centre, McMaster University, Hamilton, Canada
| | - Bettina Højberg Kirk
- Centre for Cardiac, Vascular, Pulmonary and Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - David A Wood
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver Canada
| | - John G Webb
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver Canada
| |
Collapse
|