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Feasibility and Safety of Same-Day Discharge Following Transfemoral Transcatheter Aortic Valve ReplacementFree Access

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J Am Coll Cardiol Intv, 15 (6) 575–589
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Central Illustration

Abstract

Objectives

This study evaluated the feasibility and safety of same-day discharge (SDD) following transfemoral transcatheter aortic valve replacement (TF-TAVR) compared with next-day discharge (NDD).

Background

Reducing hospital length of stay is an important goal for patients and hospitals. Cleveland Clinic implemented a post-TAVR SDD pathway beginning in March 2020.

Methods

The study retrospectively analyzed patients who underwent “minimalist” outpatient TF-TAVR in 2019 to 2020. SDD was applied to patients who met the predefined criteria. Outcomes included in-hospital and 30-day events and were compared between SDD and NDD (during and prior to availability of the SDD pathway).

Results

In 2020, SDD and NDD accounted for 22.1% (n = 114 of 516) and 63.8% (n = 329 of 516) of outpatient TF-TAVR, respectively. SDD patients in 2020, compared with NDD patients in 2019 (n = 481), were younger, were more often male, and had a lower surgical risk. There were no significant differences in in-hospital events and 30-day readmissions (cardiovascular readmission: 3.5% vs 6.2%; P = 0.37; noncardiovascular readmission: 2.6% vs 4.0%; P = 0.78), and there were no deaths after SDD. These outcomes remained consistent after propensity score matching. Only 1 (0.9%) patient required pacemaker implantation after SDD (post-TAVR day 25). As expected based on SDD criteria, multivariable logistic regression analysis identified procedure end-time as the strongest predictor of SDD (adjusted OR: 7.74; 95% CI: 4.39-13.63), while male sex and baseline hemoglobin level were also associated with SDD.

Conclusions

SDD after TF-TAVR was feasible in this early experience without impairing post-discharge safety. Our SDD pathway may serve as a useful strategy to improve bed utilization and reduce hospital stay for TAVR recipients.

Introduction

With accumulated evidence during the last decade, transcatheter aortic valve replacement (TAVR) is established as a minimally invasive treatment for patients with severe symptomatic aortic stenosis.1 Greater procedural experience and increasing knowledge of procedural complications allow for less invasive, “minimalist” TAVR in the majority of cases, leading to earlier ambulation post-procedure without compromising procedural safety.2,3 Consequently, the length of hospital stay has been significantly shortened in TAVR recipients in the United States, along with reduced health care costs.4,5 At many centers, next-day discharge (NDD) post-TAVR is quite common and is seen among more than 25% of TAVR recipients nationwide.2-4,6-9

Since the COVID-19 (coronavirus disease-2019) pandemic began worldwide in early 2020, health care systems have faced the challenges of optimizing utilization in a period of limited space and personnel resources and minimizing coronavirus exposure during hospitalization in compliance with clinical triage recommendations.10,11 Under this need for hospital management change, our institution implemented a protocol for the same-day discharge (SDD) of carefully selected TAVR recipients beginning in March 2020. In the present study, we evaluated the feasibility and safety of post-TAVR SDD based on our own criteria by comparing these patients with those undergoing TAVR with NDD at our institution in the contemporary era.

Methods

Study design and study population

The present study is a retrospective analysis conducted at the Cleveland Clinic. Data were extracted from our prospectively collected institutional registries or were manually extracted from electronic medical records. The study was approved by the Institutional Review Board of Cleveland Clinic, and the requirement of informed consent was waived due to the retrospective nature of this study.

The present analysis included consecutive patients ≥18 years of age who underwent TAVR at our institution between January 2019 and November 2020. We excluded patients who underwent nontransfemoral TAVR, those who were admitted for other treatments or examinations pre-TAVR (as these inpatient TAVR recipients were not considered candidates for SDD post-TAVR), and those who died during hospitalization. Consequently, patients who underwent transfemoral TAVR (TF-TAVR) on the day of admission (ie, outpatient TF-TAVR) and were discharged alive were eligible for the present study.

Predefined selection criteria for SDD

Candidates for SDD were determined based upon procedural characteristics and outcomes, patient comfort, and availability of social support after discharge. Our predefined selection criteria for SDD are shown in Figure 1. If a patient did not meet all of the 6 criteria for SDD but was in stable condition without the need for further observation beyond an overnight stay, the patient was typically discharged on the next day. In 2019, patients who underwent TF-TAVR without complications requiring in-hospital observation beyond overnight were typically discharged on the next day.

Figure 1
Figure 1

Selection Criteria of Candidates for SDD

∗Defined as aortic or annular complications, stroke, high-degree atrioventricular block (AVB) or complete heart block, and major vascular complications. †Stable ECG was defined as electrocardiogram (ECG) without new-onset persistent left bundle branch block, high-degree AVB or complete heart block, extended pauses, or new onset persistent first-degree AVB during post–transcatheter aortic valve replacement (TAVR) monitoring in the recovery area (chronic first-degree AVB without change was considered stable). Note: complications not affecting hemodynamic and ambulation (eg, minor vascular complications) did not exclude the possibility of same-day discharge (SDD).

Procedures and post-procedural management

Operators determined the valve type and size after heart team discussion based on annular sizing, aortic root features, and typical selection characteristics. The Sentinel cerebral embolic protection device (Boston Scientific) was generally used for all TF-TAVR patients at our institution unless there was a radial access-site or anatomic issue precluding device insertion. We systematically used a high valve deployment technique to decrease the post-TAVR permanent pacemaker (PPM) risk as previously described.12 After hemodynamic, angiographic, and transthoracic echocardiographic assessment following valve deployment, post-dilation was performed as needed for paravalvular leak closure or surgical valve fracture or modification for valve-in-valve patients. Once the final optimal result was achieved, the Sentinel device was removed, protamine sulfate was administered, and the femoral artery closure was completed. All patients had completion iliofemoral angiography performed with any peripheral interventions conducted as indicated.

After leaving the hybrid operating room, patients were transferred to the post-procedural care unit, where they were continuously monitored on telemetry until discharge. All patients had a 12-lead electrocardiogram (ECG) immediately upon arrival to the care unit as well as an ECG prior to discharge (or at serial intervals if conduction abnormalities were noted on telemetry or ECG). Complete bedside transthoracic echocardiography was performed by an echocardiography technician in the recovery area to assess the procedural results and establish the baseline TAVR gradient (typically between 1 and 4 hours after the procedure).

If the operating physicians and nurses reached the consensus based on the criteria for SDD after 6-hour careful post-TAVR bedrest observation, and the patient and their family were in agreement with SDD, the patient was discharged on the evening of the procedural day with an appointment for an outpatient visit on the next day or post-TAVR day 2 (Figure 1). An ECG patch (Zio Patch, iRhythm Technologies) was used for ambulatory ECG monitoring following discharge at the discretion of the care team and was usually applied to patients with evidence of new significant conduction deficits (typically new onset persistent left bundle branch block [LBBB] or right bundle branch block or first-degree atrioventricular block [AVB] with a PR-interval longer than prior to TAVR) who were typically not discharged until the next day or beyond depending on the duration of inpatient rhythm monitoring.

Patient characteristics and outcomes

The following baseline and procedural characteristics were evaluated: age, sex, body mass index, The Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), prior cardiovascular history, comorbidities, baseline laboratory, ECG and echocardiographic findings, and procedural information (type and size of valve used, Sentinel cerebral protection device use, and procedure end time [before or after noon on the procedure date]).

Outcomes measured were in-hospital and 30-day post-discharge events, defined according to the Valve Academic Research Consortium-3 criteria.13 Thirty-day post-discharge events were defined as outcomes occurring from discharge to 30 days post-TAVR and included death, any-cause readmission, cardiovascular and noncardiovascular readmission, the timing of readmission, and detailed post-discharge events such as PPM or implantable cardioverter-defibrillator (ICD) implantation and stroke. No patient was lost to follow-up at 30 days post-TAVR.

Statistical analyses

Categorical variables were presented as numbers and percentages and were compared using Fisher exact test or chi-square test. Continuous variables were presented as median (IQR) and were compared using the Mann-Whitney U test. First, we described the clinical characteristics and outcomes of patients discharged early (SDD or NDD) and compared them between 2019 and 2020. Next, to examine the safety of SDD relative to NDD, we compared the outcomes between SDD patients in 2020 and NDD patients in 2019. Because the patient selection may bias the results of outcomes, we also performed a propensity score matching to adjust for potential confounding factors between the groups. Propensity scores for SDD were estimated using a multivariable logistic regression model including the following clinically relevant baseline and procedural characteristics as covariates: age, sex, STS-PROM, pre-existing PPM or ICD, end-stage renal disease on dialysis, hemoglobin level, estimated glomerular filtration rate, atrial fibrillation rhythm, pre-existing first-degree AVB and right bundle branch block, left ventricular ejection fraction, failed bioprosthetic valve, and valve type used for TAVR. One-to-one matching was performed using the nearest-neighbor method without replacement with a caliper within 0.1 times the pooled SD of the logit of the propensity scores. Last, we examined the predictors of SDD (vs NDD in 2020) using a multivariable logistic regression model in which the previous clinically relevant variables as well as procedure end time (before or after noon) were included as covariates. A 2-sided P value of <0.05 was set as significant in all hypothesis tests. All statistical analyses were conducted using IBM SPSS Statistics, version 27 (IBM Corporation).

Results

Study population

Over the time period studied, 1,315 patients underwent TAVR at our institution. As per the criteria of this study, 1,113 patients (median age 79.0 [IQR: 73.0-84.0] years; 40.1% female; median STS-PROM 4.2% [IQR: 2.7%-6.6%]) underwent outpatient TF-TAVR, including 597 in 2019 and 516 in 2020 (Figure 2A). Comparative data between 597 patients in 2019 and 516 patients in 2020 are shown in Supplemental Table 1, demonstrating similar in-hospital adverse events between the 2 study years.

Figure 2
Figure 2

Study Patients and Timing of Hospital Discharge

(A) Selection of the patients for the present study. (B) Timing of post-TAVR hospital discharge in 2019 and 2020. NDD = next-day discharge; TF = transfemoral; other abbreviations as in Figure 1.

The rate of in-hospital PPM or ICD implantation was 1.8% and 2.1% in 2019 and 2020, respectively. While no patient died within 30 days in 2019, 4 (0.8%) patients died within 30 days in 2020 (the details of the 4 patients are shown in Supplemental Table 2): 2 patients died due to intracranial hemorrhage during readmission after NDD (1 on day 19 and 1 on day 26), and the other 2 patients experienced out-of-hospital death of unknown etiology (1 on post-TAVR day 12 after an initial NDD and 1 on post-TAVR day 29 after having been discharged on day 3 after TAVR). The other 30-day outcomes did not differ between 2019 and 2020.

In 2019, NDD accounted for 80.6% (n = 481 of 597) of patients, while in 2020, SDD and NDD accounted for 22.1% (n = 114 of 516) and 63.8% (n = 329 of 516), respectively (Figure 2B). Overall, SDD or NDD patients, as compared with patients discharged day 2 or later, were younger and had a lower STS-PROM with fewer comorbidities and fewer in-hospital complications, with no significant difference in 30-day outcomes except for a lower bleeding event rate (Supplemental Table 3).

Comparison of patients with SDD or NDD between 2019 and 2020

When compared with NDD patients in 2019, SDD or NDD patients in 2020 had a lower STS-PROM (Table 1). Owing to slight differences in practice pattern, our group had a greater use of self-expanding valve platforms in 2020 than in 2019. No significant differences were observed between the groups in terms of in-hospital and 30-day post-discharge outcomes.

Table 1 Patient Characteristics and Outcomes Between 2019 vs 2020 Among Patients Discharged Early Following TAVR

Next-Day Discharge in 2019 (n = 481)Same-Day or Next-Day Discharge in 2020 (n = 443)P Value
Baseline patient characteristics
 Age, y79.0 (73.0-85.0)78.0 (72.0-83.5)0.064
 Female180 (37.4)177 (40.0)0.46
 Body mass index, kg/m227.7 (24.5-32.7)28.3 (25.1-33.7)0.15
 STS-PROM, %4.4 (2.8-6.7)3.7 (2.4-5.8)0.001
 Prior PPM/ICD implantation72 (15.0)59 (13.3)0.51
 Prior CABG92 (19.1)85 (19.2)1.00
 Prior myocardial infarction93 (19.3)79 (17.8)0.61
 Prior stroke62 (12.9)39 (8.8)0.057
 History of atrial fibrillation/flutter188 (39.1)183 (41.3)0.50
 Hypertension431 (89.6)404 (91.2)0.44
 Diabetes mellitus177 (36.8)166 (37.5)0.84
 ESRD on dialysis13 (2.7)10 (2.3)0.68
 Chronic lung disease185 (38.5)175 (39.5)0.79
 NYHA functional class III or IV273 (56.8)288 (65.0)0.011
Baseline laboratory findings
 Hemoglobin level, g/dL13.0 (11.8-13.9)13.1 (11.8-14.1)0.54
 eGFR, mL/min/1.73 m261.8 (50.2-76.3)62.5 (48.0-76.7)0.87
Baseline ECG findings
 Atrial fibrillation rhythm58 (12.1)46 (10.4)0.47
 First-degree AVB94 (19.5)79 (17.8)0.55
 RBBB56 (11.6)44 (9.9)0.46
 LBBB25 (5.2)28 (6.3)0.48
Valve and echocardiographic findings
 LVEF, %60 (55-65)60 (54-65)0.50
 Aortic valve mean gradient, mm Hg41.0 (32.0-51.0)38 (29.5-47.0)0.011
 Bicuspid aortic valve32 (6.7)23 (5.2)0.40
 Failed bioprosthetic valve42 (8.7)57 (12.9)0.044
 Moderate or severe AR88 (18.3)86 (19.4)0.67
Procedure
 Valve type<0.001
  Balloon-expandable (SAPIEN 3/3 Ultra)454 (94.4)385 (86.9)
  Self-expanding (Evolut R/PRO/PRO+)27 (5.6)52 (11.7)
  Mechanically expandable (Lotus Edge)0 (0.0)6 (1.4)
 Valve size0.94
  ≤23 mm180 (37.4)161 (36.3)
  25-27 mm182 (37.8)172 (38.8)
  ≥29 mm119 (24.7)110 (24.8)
 Sentinel cerebral protection468 (97.3)419 (94.6)0.043
 Procedure ended before noon196 (40.7)222 (50.1)0.004
In-hospital adverse events
 Major vascular complication0 (0.0)0 (0.0)
 Minor vascular complication46 (9.6)43 (9.7)1.00
 Vascular intervention46 (9.6)43 (9.7)1.00
 Coronary compression1 (0.2)1 (0.2)1.00
 PCI5 (1.0)4 (0.9)1.00
 Annular/aortic dissection0 (0.0)0 (0.0)
 Conversion to open surgery0 (0.0)0 (0.0)
 Second valve deployment2 (0.4)1 (0.2)1.00
 Access-site bleeding6 (1.2)5 (1.1)1.00
 Ischemic stroke0 (0.0)1 (0.2)0.48
 TIA2 (0.4)0 (0.0)0.50
 HAVB/CHB2 (0.4)3 (0.7)0.67
 New onset LBBB32 (6.7)45 (10.2)0.057
 PPM/ICD implantation0 (0.0)0 (0.0)
 Paravalvular leak ≥2+2 (0.4)1 (0.2)1.00
Discharge disposition0.30
 Home469 (97.5)435 (98.2)
 Hotel7 (1.5)7 (1.6)
 SNF or other facility5 (1.0)1 (0.2)
30-d post-discharge outcomes
 Death0 (0.0)3 (0.7)0.11
 Any-cause readmission49 (10.2)30 (6.8)0.077
  Cardiovascular readmission30 (6.2)21 (4.7)0.39
   Procedure/valve-related readmission19 (4.0)14 (3.2)0.60
     New complications10 (2.1)11 (2.5)0.83
     Exacerbation of previous in-hospital complication1 (0.2)0 (0.0)1.00
     Bioprosthetic valve dysfunction0 (0.0)0 (0.0)
     Bleeding complications related to anticoagulant/antiplatelet5 (1.0)2 (0.5)0.45
     Heart failure4 (0.8)1 (0.2)0.38
   Other cardiovascular readmission11 (2.3)7 (1.6)0.48
  Timing of cardiovascular readmission
   Week 1 (discharge to post-TAVR day 7)15 (3.1)10 (2.3)0.54
   Week 2 (post-TAVR days 8-14)6 (1.2)4 (0.9)0.75
   Week 3 (post-TAVR days 15-21)5 (1.0)3 (0.7)0.73
   Week 4 (post-TAVR days 22-30)5 (1.0)5 (1.1)1.00
  Noncardiovascular readmission19 (4.0)11 (2.5)0.27
  Timing of noncardiovascular readmission
   Week 1 (discharge-post-TAVR day 7)8 (1.7)5 (1.1)0.58
   Week 2 (post-TAVR days 8-14)6 (1.2)1 (0.2)0.13
   Week 3 (post-TAVR days 15-21)5 (1.0)3 (0.7)0.73
   Week 4 (post-TAVR days 22-30)2 (0.4)2 (0.5)1.00
 PPM/ICD implantation3 (0.6)5 (1.1)0.49
 Aortic valve reintervention0 (0.0)0 (0.0)
 Infective endocarditis0 (0.0)0 (0.0)
 Myocardial infarction1 (0.2)1 (0.2)1.00
 Ischemic stroke0 (0.0)2 (0.5)0.23
 TIA1 (0.2)0 (0.0)1.00
 Hemorrhagic stroke0 (0.0)2 (0.5)0.23
 Major vascular complication0 (0.0)0 (0.0)
 Minor vascular complication2 (0.4)1 (0.2)1.00
 Bleeding event5 (1.0)2 (0.5)0.45

Values are median (IQR) or n (%).

AR = aortic regurgitation; AVB = atrioventricular block; CABG = coronary artery bypass grafting; CHB = complete heart block; ECG = electrocardiogram; ESRD = end-stage renal disease; eGFR = estimated glomerular filtration rate; HAVB = high-degree atrioventricular block; ICD = implantable cardioverter-defibrillator; LBBB = left bundle branch block; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association; PCI = percutaneous coronary intervention; PPM = permanent pacemaker; RBBB = right bundle branch block; SNF = skilled nursing facility; STS-PROM = The Society of Thoracic Surgeons Predicted Risk of Mortality; TAVR = transcatheter aortic valve replacement; TIA = transient ischemic attack.

∗ Noncerebral.

Safety of SDD in 2020 compared with NDD in 2019

Patients with SDD in 2020, compared with those with NDD in 2019, were younger, were more often male, had a lower STS-PROM, and had a lower prevalence of prior stroke and a higher baseline hemoglobin level (Table 2, A vs B). Patients with SDD in 2020 were discharged to a hotel (if from out of town) slightly more frequently than those with NDD in 2019. The rates of in-hospital adverse events and 30-day readmissions did not differ significantly between the 2 groups (Table 3, A vs B). No patient in either group died within 30 days. The rate of post-discharge PPM/ICD implantation at 30 days was similarly low between SDD patients in 2020 and NDD patients in 2019 (0.9% vs 0.6%; P = 0.57). The propensity score–matched analyses demonstrated results consistent with the unmatched analyses (Supplemental Table 4).

Table 2 Patient and Procedural Characteristics of Same-Day vs Next-Day Discharge

(A) Next-Day Discharge in 2019 (n = 481)(B) Same-Day Discharge in 2020 (n = 114)(C) Next-Day Discharge in 2020 (n = 329)P Value
A vs BB vs C
Baseline patient characteristics
 Age, y79.0 (73.0-85.0)77.5 (72.0-82.0)79.0 (73.0-84.0)0.0090.054
 Female180 (37.4)28 (24.6)149 (45.3)0.012<0.001
 Body mass index, kg/m227.7 (24.5-32.7)27.5 (24.5-32.4)28.3 (25.1-34.1)1.000.20
 STS-PROM, %4.4 (2.8-6.7)2.8 (2.0-4.1)4.0 (2.6-6.3)<0.001<0.001
 STS-PROM category<0.001<0.001
 Low (<4%)209 (43.5)84 (73.7)162 (49.2)
 Intermediate (4-8%)191 (39.7)23 (20.2)112 (34.0)
 High (>8%)81 (16.8)7 (6.1)55 (16.7)
 Prior PPM/ICD implantation72 (15.0)15 (13.2)44 (13.4)0.771.00
 Prior CABG92 (19.1)26 (22.8)59 (17.9)0.360.27
 Prior myocardial infarction93 (19.3)17 (14.9)62 (18.8)0.350.40
 Prior stroke62 (12.9)5 (4.4)34 (10.3)0.0080.056
 History of atrial fibrillation/flutter188 (39.1)43 (37.7)140 (42.6)0.830.38
 Hypertension431 (89.6)99 (86.8)305 (92.7)0.400.082
 Diabetes mellitus177 (36.8)33 (28.9)133 (40.4)0.130.033
 ESRD on dialysis13 (2.7)2 (1.8)8 (2.4)0.751.00
 Chronic lung disease185 (38.5)38 (33.3)137 (41.6)0.330.12
 NYHA functional class III or IV273 (56.8)66 (57.9)222 (67.5)0.830.069
Baseline laboratory findings
 Hemoglobin level, g/dL13.0 (11.8-13.9)13.7 (12.4-14.9)12.8 (11.7-13.8)<0.001<0.001
 eGFR, mL/min/1.73 m261.8 (50.2-76.3)63.8 (50.6-79.6)61.4 (47.8-76.8)0.420.25
Baseline ECG findings
 Atrial fibrillation rhythm58 (12.1)10 (8.8)36 (10.9)0.410.60
 First-degree AVB94 (19.5)18 (15.8)61 (18.5)0.420.57
 RBBB56 (11.6)10 (8.8)34 (10.3)0.510.72
 LBBB25 (5.2)9 (7.9)19 (5.8)0.260.50
Valve and echocardiographic findings
 LVEF, %60 (55-65)60 (55-65)59 (53-65)0.960.48
 Aortic valve mean gradient, mm Hg41.0 (32.0-51.0)40.0 (29.0-48.0)38.0 (30.0-47.0)0.150.79
 Bicuspid aortic valve32 (6.7)5 (4.4)18 (5.5)0.520.81
 Failed bioprosthetic valve42 (8.7)16 (14.0)41 (12.5)0.110.75
 Moderate or severe AR88 (18.3)17 (14.9)69 (21.0)0.490.17
Procedure
 Valve type0.200.17
  Balloon expandable (SAPIEN 3/3 Ultra)454 (94.4)104 (91.2)281 (85.4)
  Self-expanding (Evolut R/PRO/PRO+)27 (5.6)10 (8.8)42 (12.8)
  Mechanically expandable (Lotus Edge)0 (0.0)0 (0.0)6 (1.8)
 Valve size0.130.073
  ≤23 mm180 (37.4)32 (28.1)129 (39.2)
  25-27 mm182 (37.8)53 (46.5)119 (36.2)
  ≥29 mm119 (24.7)29 (25.4)81 (24.6)
 Sentinel cerebral protection468 (97.3)112 (98.2)307 (93.3)0.750.053
 Procedure ended before noon196 (40.7)95 (83.3)127 (38.6)<0.001<0.001

Values are median (IQR) or n (%).

Abbreviations as in Table 1.

Table 3 In-Hospital and 30-Day Post-Discharge Outcomes of Same-Day vs Next-Day Discharge

(A) Next-Day Discharge in 2019 (n = 481)(B) Same-Day Discharge in 2020 (n = 114)(C) Next-Day Discharge in 2020 (n = 329)P Value
A vs BB vs C
In-hospital adverse events
 Major vascular complication0 (0.0)0 (0.0)0 (0.0)
 Minor vascular complication46 (9.6)7 (6.1)36 (10.9)0.360.15
 Vascular intervention46 (9.6)7 (6.1)36 (10.9)0.360.15
 Coronary compression1 (0.2)0 (0.0)1 (0.3)1.001.00
 PCI5 (1.0)0 (0.0)4 (1.2)0.590.58
 Annular/aortic dissection0 (0.0)0 (0.0)0 (0.0)
 Conversion to open surgery0 (0.0)0 (0.0)0 (0.0)
 Second valve deployment2 (0.4)1 (0.9)0 (0.0)0.470.26
 Access-site bleeding6 (1.2)0 (0.0)5 (1.5)0.600.33
 Ischemic stroke0 (0.0)0 (0.0)1 (0.3)1.00
 TIA2 (0.4)0 (0.0)0 (0.0)1.00
 HAVB/CHB2 (0.4)0 (0.0)3 (0.9)1.000.57
 New onset LBBB32 (6.7)6 (5.3)39 (11.9)0.680.048
 PPM/ICD implantation0 (0.0)0 (0.0)0 (0.0)
 Paravalvular leak ≥2+2 (0.4)0 (0.0)1 (0.3)1.001.00
Discharge disposition0.044<0.001
 Home469 (97.5)107 (93.9)328 (99.7)
 Hotel7 (1.5)6 (5.3)1 (0.3)
 SNF or other facility5 (1.0)1 (0.9)0 (0.0)
30-d post-discharge outcomes
 Death0 (0.0)0 (0.0)3 (0.9)0.57
 Any-cause readmission49 (10.2)7 (6.1)23 (7.0)0.210.83
  Cardiovascular readmission30 (6.2)4 (3.5)17 (5.2)0.370.61
   Procedure/valve-related readmission19 (4.0)2 (1.8)12 (3.6)0.400.53
     New complications10 (2.1)1 (0.9)10 (3.0)0.700.30
     Exacerbation of previous in-hospital complication1 (0.2)0 (0.0)0 (0.0)1.00
     Bioprosthetic valve dysfunction0 (0.0)0 (0.0)0 (0.0)
     Bleeding complications related to anticoagulant/antiplatelet5 (1.0)1 (0.9)1 (0.3)1.000.45
     Heart failure4 (0.8)0 (0.0)1 (0.3)1.001.00
   Other cardiovascular readmission11 (2.3)2 (1.8)5 (1.5)1.001.00
  Timing of cardiovascular readmission
   Week 1 (discharge to post-TAVR day 7)15 (3.1)2 (1.8)8 (2.4)0.751.00
   Week 2 (post-TAVR days 8-14)6 (1.2)0 (0.0)4 (1.2)0.600.58
   Week 3 (post-TAVR days 15-21)5 (1.0)1 (0.9)2 (0.6)1.001.00
   Week 4 (post-TAVR days 22-30)5 (1.0)1 (0.9)4 (1.2)1.001.00
  Noncardiovascular readmission19 (4.0)3 (2.6)8 (2.4)0.781.00
  Timing of noncardiovascular readmission
   Week 1 (discharge-post-TAVR day 7)8 (1.7)1 (0.9)4 (1.2)1.001.00
   Week 2 (post-TAVR days 8-14)6 (1.2)0 (0.0)1 (0.3)0.601.00
   Week 3 (post-TAVR days 15-21)5 (1.0)1 (0.9)2 (0.6)1.001.00
   Week 4 (post-TAVR days 22-30)2 (0.4)1 (0.9)1 (0.3)0.470.45
 PPM/ICD implantation3 (0.6)1 (0.9)4 (1.2)0.571.00
 Aortic valve reintervention0 (0.0)0 (0.0)0 (0.0)
 Infective endocarditis0 (0.0)0 (0.0)0 (0.0)
 Myocardial infarction1 (0.2)1 (0.9)0 (0.0)0.350.26
 Ischemic stroke0 (0.0)0 (0.0)2 (0.6)1.00
 TIA1 (0.2)0 (0.0)0 (0.0)1.00
 Hemorrhagic stroke0 (0.0)0 (0.0)2 (0.6)1.00
 Major vascular complication0 (0.0)0 (0.0)0 (0.0)
 Minor vascular complication2 (0.4)0 (0.0)1 (0.3)1.001.00
 Bleeding event5 (1.0)1 (0.9)1 (0.3)1.000.45

Values are n (%).

Abbreviations as in Table 1.

Predictors and outcomes of SDD vs NDD in 2020

Patients with SDD in 2020, compared with those with NDD in 2020, were more often male, had a lower STS-PROM, and had a higher baseline hemoglobin level (Table 2, B vs C). The procedure ended much more frequently before noon in SDD patients (83.3% vs 38.6%; P < 0.001) than NDD patients, consistent with the selection criteria as described for the SDD group. Multivariable analysis identified procedure end time (before vs after noon) as the strongest predictor of SDD (adjusted odds ratio: 7.74). Other factors associated with SDD were male sex and higher baseline hemoglobin level (Figure 3).

Figure 3
Figure 3

Predictors of SDD (vs NDD) After TF-TAVR in 2020

No multicollinearity was present among the covariates in the model (all variance inflation factor values <2.0). eGFR = estimated glomerular filtration rate; ESRD = end-stage renal disease; ICD = implantable cardioverter-defibrillator; LVEF = left ventricular ejection fraction; NDD = next-day discharge; PPM = permanent pacemaker; RBBB = right bundle branch block; STS = Society of Thoracic Surgeons; other abbreviations as in Figure 1.

New onset LBBB was less frequent in SDD patients than NDD patients (5.3% vs 11.9%; P = 0.048). While 3 patients with NDD died within 30 days after TAVR (as detailed previously and in Supplemental Table 2), no patient with SDD died within 30 days. The 30-day post-discharge outcomes did not differ between the 2 groups (Table 3, B vs C).

Post-TAVR management and 30-day outcomes after SDD

In the SDD group (n = 114), 6 (5.3%) patients developed new onset LBBB during the TAVR procedure, all of whom resolved this conduction abnormality before discharge and without leading to advanced conduction disturbances thereafter. Among 99 SDD patients without pre-existing PPM/ICD, 2 (2.0%) were discharged with a Zio Patch (one for follow-up after resolution of new onset LBBB and the other for follow-up of post-TAVR transient junctional rhythm in a patient with baseline sinus bradycardia and first-degree AVB). None of these patients required PPM or ICD implantation post-discharge.

Seven (6.1%) patients were readmitted within 30 days after SDD (the details of the 7 patients are shown in Table 4), including 2 patients readmitted on the day after discharge (one for a tachycardia on a background of paroxysmal atrial fibrillation and the other for post-discharge fever). One patient was readmitted with symptomatic intermittent complete heart block on post-TAVR day 25 resulting in PPM implantation. This patient had no significant conduction disease on the ECG prior to the SDD. Another patient was readmitted with pulmonary edema secondary to hypertensive emergency on post-TAVR day 7, complicated by type 2 non–ST-segment elevation myocardial infarction. Of the remaining 3 patients readmitted within 30 days after SDD, the causes of readmission were bacteremia, gastrointestinal bleeding related to dual antiplatelet therapy, and vomiting and diarrhea.

Table 4 Details of 7 Patients Readmitted Within 30 Days After Same-Day Discharge

CaseAge (y), SexPrior PPM/ICDSTS-PROM (%)Pre-TAVR Hemoglobin Level (g/dL)Pre-TAVR eGFR (mL/min/1.73 m2)Baseline LVEF, %Baseline AV Area (cm2), Mean/Peak Gradient (mm Hg)Pre-TAVR PR/QRS Duration (ms)Post-TAVR PR/QRS Duration (ms)Valve and Implanted ProsthesisSentinel Cerebral ProtectionIn-Hospital Adverse EventTime of ReadmissionCause for ReadmissionLength of Readmission (days)Discharge Status of Readmission
180, MPPM9.216.247.6570.74, 22/34AF/96AF/100Native tricuspid valve, SAPIEN 3 Ultra 26 mmYesNoneDay 7Pulmonary edema complicated by type II non–ST-segment elevation5Alive
2103, FPPM35.014.038.1550.40, 34/48AF/136 (pre-existing LBBB)AF/134 (pre-existing LBBB)Native tricuspid valve, SAPIEN 3 Ultra 26 mmYesFemoral PTA to facilitate hemostasisDay 26Bacteremia22Alive
379, MNone2.310.728.6560.79, 57/96186/92ECG immediately after TAVR 226/142 (new onset LBBB); ECG pre-discharge 230/92Native tricuspid valve, SAPIEN 3 29 mmYesNew onset LBBB that resolved before dischargeDay 15Gastrointestinal bleeding related to DAPT4Alive
472, MNone8.213.062.5450.86, 27/47214/100230/116Native tricuspid valve, Evolut PRO+ 29 mmYesNoneDay 1Known paroxysmal AF with rapid ventricular response1Alive
569, FNone3.115.285.8640.70, 36/62142/86162/92Native bicuspid valve, SAPIEN 3 Ultra 20 mmYesNoneDay 1Fever (transient)1Alive
682, FNone3.011.846.1620.72, 53/78158/126 (pre-existing IVCD)166/108Native tricuspid valve, SAPIEN 3 Ultra 26 mmYesNoneDay 17Vomiting and diarrhea3Alive
786, FNone2.613.869.0710.89, 51/63174/96ECG immediately after TAVR 192/120; ECG pre-discharge 172/110Native tricuspid valve, SAPIEN 3 23 mmYesNoneDay 25Intermittent CHB requiring PPM2Alive

AF = atrial fibrillation; DAPT = dual antiplatelet therapy; F = female; IVCD = intraventricular conduction delay; M = male; PTA = percutaneous transluminal angioplasty; other abbreviations as in Table 1.

Discussion

The present study found that >80% of TAVR recipients were discharged on the same day or the next day post-TAVR in 2019-2020, with SDD accounting for >20% in 2020. Patient characteristics were mostly similar between SDD and NDD except for a slightly younger age, a higher prevalence of men, and lower STS-PROM in SDD patients. While SDD patients had less frequent in-hospital adverse events than NDD patients as per the selection criteria for SDD, 30-day outcomes did not significantly differ (Central Illustration). Procedure end time (before vs after noon), male sex, and higher baseline hemoglobin level were associated with SDD.

Central Illustration
Central Illustration

Same-Day Discharge after TF-TAVR Is Feasible and Safe in Selected Patients Based on Cleveland Clinic Criteria

AVB = atrioventricular block; CHB = complete heart block; CV = cardiovascular; DAPT = dual antiplatelet therapy; EGD = esophagogastroduodenoscopy; GI = gastrointestinal; ICD = implantable cardioverter-defibrillator; IV = intravenous; NDD = next-day discharge; POD = postoperative day; PPM = permanent pacemaker; SAPT = single antiplatelet therapy; SDD = same-day discharge; TAVR = transcatheter aortic valve replacement; TF = transfemoral; TTE = transthoracic echocardiography.

Safety of SDD vs NDD

The current literature on post-TAVR SDD is limited to 1 case report,14 2 small case series’ (n = 3-6),15,16 and 1 single-center study at Emory University Hospital Midtown with a limited number of patients (n = 29).17 To our knowledge, the present study is the largest published experience of post-TAVR SDD. Consistent with our predefined criteria, SDD patients had a lower in-hospital adverse event rate than NDD patients. Importantly, there was no significant difference in 30-day outcomes between SDD and NDD during 2020, and in comparison with a historic “control” of NDD patients undergoing TAVR in 2019 prior to the initiation of our SDD protocol. This finding suggests that our criteria for SDD successfully selects appropriate patients without compromising their post-discharge safety. Also, the zero 30-day mortality in our SDD patients further supports the safety of SDD, similar to the Emory study.17

Selection for SDD

Compared with the Emory University SDD study,17 our 6 criteria for SDD are less strict, without any restriction on patient characteristics such as age, STS-PROM, and baseline cardiac and laboratory findings, suggesting the applicability of our SDD criteria to a broader spectrum of TAVR recipients. In this regard, SDD may be important for patients at the higher end of the age spectrum, as these patients are prone to delirium during hospital stay, which is known to be associated with increased morbidity and mortality among general inpatients as well as TAVR recipients.18,19 It would therefore stand to reason that these patients may benefit from an earlier discharge and return to familiar surroundings, though this is purely conjectural and was not specifically studied.

Major complications (stroke, complete heart block, major vascular complications) occurring during or immediately after TAVR generally preclude SDD because of the need for observation or treatment of these complications.17 However, minor complications (such as minor vascular complications successfully managed conservatively or with interventions) do not always require observation beyond 6 hours post-TAVR if post-procedural hemodynamics are stable. In this context, careful 6-hour observation of hemodynamic and electrocardiographic status as well as the access sites is a key to successful SDD.

As we became more comfortable with the SDD pathway, we made an effort to schedule those patients who were more likely to be discharged on the same day as the first and second cases of the day. Practically speaking, this involved not scheduling inpatients or those arriving from skilled nursing facilities as the first or second procedure, and also speaking with patients during their prior outpatient visit about the likelihood of SDD. This schedule management probably strengthened the association between the procedure end time and the likelihood of SDD.

In the present study, SDD (compared with NDD) patients were slightly younger with a lower STS-PROM, comparable to previous comparisons between NDD vs later discharge.3 Of note, age and STS-PROM, as well as cardiac or renal function, were not significantly associated with SDD in the multivariable model. Meanwhile, male sex was associated with a higher likelihood of SDD than women even after adjustment for age, surgical risk, and other parameters, similar to a previous Emory University study identifying male sex as a strong predictor of NDD.3 This sex-related finding might be partly attributable to physicians’ possible concerns for higher risk of vascular and bleeding complications among women than among men.20,21 In addition, frailty, albeit not evaluated in the present study, might be more common in female TAVR recipients, leading to more frequent avoidance of SDD.22 Beyond these conjectures, reasons for these sex differences of SDD remain unknown and merits further investigation.

It is important to note that our criteria for SDD are primarily objective criteria and therefore applicable widely. The pre-discharge discussion between the caregivers and the patient is rather a subjective matter but was important to determine whether the patient was comfortable with ambulation after bedrest and also with the idea of discharge on the same day with adequate social support. The reasons for deferring SDD for patients whose procedure was completed before noon were not documented. Anecdotally, the most common reasons included the need for additional ECG monitoring, absence of social support on the evening of discharge, and a lack of comfort on the part of the patient to leave on the same day.

Concern for delayed conduction disorder after SDD

Delayed conduction disturbance post-discharge due to limited monitoring is a concern when discharging patients early after TAVR.23-26 However, our PPM or ICD rate from discharge to 30 days was low (0.7% in 2019 and 1.0% in 2020), which was comparable to that in recent post-TAVR NDD studies.2,3 These observations support that advanced conduction disorders are uncommon after discharge in patients carefully selected for SDD or NDD. It should be noted that all patients who developed a new-onset LBBB during or after TAVR and were discharged as part of the SDD pathway had resolved this conduction disturbance with a return to baseline QRS duration on subsequent ECGs prior to discharge; those who did not were observed at least until the next day.

In our 114 SDD cases, only 1 (0.9%) patient required post-discharge late PPM implantation (readmitted on day 25 post-TAVR) for intermittent complete heart block. This patient had no concerning ECG changes (PR prolongation, bundle branch block, etc.) after TAVR both prior to the SDD and on post-discharge follow-up that would have predicted PPM implantation. Therefore, discharge even the next day or later would not have changed this outcome. Optimal post-TAVR observation time with continuous ECG monitoring has not been established yet due to a lack of evidence.24,25 There is consensus that early discharge should not be carried out in patients with periprocedural advanced conduction disturbances or those with pre-existing conduction disturbances and worsening ECG changes post-procedure due to the high possibility of PPM requirement.24,25 Ambulatory ECG monitoring may be useful in facilitating safe early discharge post-TAVR.15,26 However, routine ambulatory monitoring is not incorporated into our SDD pathway, as is the same in the Emory University SDD pathway17 and other NDD pathways.2,3

As previously described, we routinely implant our valve with very little protrusion into the left ventricular outflow tract, which in the initial published series cited was 5.5%, and in the years since that study has been even lower.12 This is lower than most published series’ and the Transcatheter Valve Therapy Registry.4 While this is a factor in the absolute number of patients that are eligible for SDD, it does not detract from the generalizability of our selection criteria to other centers.

Study limitations

The present study was conducted at a single center with a significant preference for balloon-expandable valves deployed at a high position resulting in low post-TAVR conduction deficits, and an overall low risk of periprocedural complications over more than 15 years of performing TAVR. Hence, the present data may not be directly generalizable, especially for institutions with a higher use of self-expanding valves or less procedural experience. Although our cohort included the largest SDD patients, it may have been too small to statistically detect differences in 30-day outcomes between SDD and NDD if such a difference truly existed. Application to certain high-risk subsets (eg, patients with pre-existing right bundle branch block) is also limited due to the small sample of those patients in our SDD cohort.

Conclusions

The present study demonstrates that SDD among “minimalist” outpatient TF-TAVR recipients selected carefully based on our criteria was safe with similar post-discharge safety to patients discharged on the day after TAVR during the same period and the year prior. Patients can be candidates for SDD if the procedure is performed without complication and without concerning post-TAVR conduction disease. This pathway may provide benefits in optimizing limited health care resource utilization (ie, personnel and bed availability) and minimizing infectious exposure of patients to life-threatening viruses, both of which have become common issues in recent years. Future large multicenter studies will be beneficial to confirm our findings with respect to the feasibility and safety of SDD post-TAVR and make SDD more widely acceptable in routine clinical practice.

Perspectives

WHAT IS KNOWN? Owing to less invasive “minimalist” TF-TAVR in recent years, NDD is common among >25% of TAVR recipients nationwide. However, literature on the feasibility and safety of post-TAVR SDD is limited to small studies (sample size <30).

WHAT IS NEW? This single-center study demonstrated that SDD was feasible in selected TF-TAVR recipients (approximately 20%) based on our predefined criteria without impairing post-discharge safety (at 30 days, cardiovascular readmission 3.5%; noncardiovascular readmission 2.6%; no death), with 1 (0.9%) patient needing permanent pacemaker post-SDD.

WHAT IS NEXT? Future large multicenter studies are warranted to confirm our findings with respect to the generalizable feasibility and safety of SDD post-TAVR to make this pathway more widely acceptable.

Funding Support and Author Disclosures

This manuscript was made possible by a generous grant provided by Mr Chinh Chu. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Abbreviations and Acronyms

AVB

atrioventricular block

ECG

electrocardiogram

ICD

implantable cardioverter-defibrillator

LBBB

left bundle branch block

NDD

next-day discharge

PPM

permanent pacemaker

SDD

same-day discharge

STS-PROM

The Society of Thoracic Surgeons Predicted Risk of Mortality

TAVR

transcatheter aortic valve replacement

TF-TAVR

transfemoral transcatheter aortic valve replacement

References

  • 1. Otto C.M., Nishimura R.A., Bonow R.O., et al. "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol 2021;77:e25-e197.

    View ArticleGoogle Scholar
  • 2. Wood D.A., Lauck S.B., Cairns J.A., et al. "The Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway facilitates safe next-day discharge home at low-, medium-, and high-volume transfemoral transcatheter aortic valve replacement centers: the 3M TAVR study". J Am Coll Cardiol Intv 2019;12:459-469.

    View ArticleGoogle Scholar
  • 3. Kamioka N., Wells J., Keegan P., et al. "Predictors and clinical outcomes of next-day discharge after minimalist transfemoral transcatheter aortic valve replacement". J Am Coll Cardiol Intv 2018;11:107-115.

    View ArticleGoogle Scholar
  • 4. Carroll J.D., Mack M.J., Vemulapalli S., et al. "STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement". J Am Coll Cardiol 2020;76:2492-2516.

    View ArticleGoogle Scholar
  • 5. Alkhouli M., Alqahtani F., Ziada K.M., Aljohani S., Holmes D.R., Mathew V. "Contemporary trends in the management of aortic stenosis in the USA". Eur Heart J 2020;41:921-928.

    CrossrefMedlineGoogle Scholar
  • 6. Yerasi C., Tripathi B., Wang Y., et al. "National trends and 30-day readmission rates for next-day-discharge transcatheter aortic valve replacement: An analysis from the Nationwide Readmissions Database, 2012-2016". Am Heart J 2021;231:25-31.

    CrossrefMedlineGoogle Scholar
  • 7. Moriyama N., Vento A., Laine M. "Safety of next-day discharge after transfemoral transcatheter aortic valve replacement with a self-expandable versus balloon-expandable valve prosthesis". Circ Cardiovasc Interv 2019;12: e007756.

    CrossrefMedlineGoogle Scholar
  • 8. Ichibori Y., Li J., Davis A., et al. "Feasibility and safety of adopting next-day discharge as first-line option after transfemoral transcatheter aortic valve replacement". J Invasive Cardiol 2019;31:64-72.

    MedlineGoogle Scholar
  • 9. Costa G., Barbanti M., Picci A., et al. "Predictors and safety of next-day discharge in patients undergoing transfemoral transcatheter aortic valve implantation". EuroIntervention 2020;16:e494-e501.

    CrossrefMedlineGoogle Scholar
  • 10. Shah P.B., Welt F.G.P., Mahmud E., et al. "Triage considerations for patients referred for structural heart disease intervention during the COVID-19 pandemic: an ACC/SCAI Position Statement". J Am Coll Cardiol Intv 2020;13:1484-1488.

    View ArticleGoogle Scholar
  • 11. Welt F.G.P., Shah P.B., Aronow H.D., et al. "Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic: from the ACC's Interventional Council and SCAI". J Am Coll Cardiol 2020;75:2372-2375.

    View ArticleGoogle Scholar
  • 12. Sammour Y., Banerjee K., Kumar A., et al. "Systematic approach to high implantation of SAPIEN-3 valve achieves a lower rate of conduction abnormalities including pacemaker implantation". Circ Cardiovasc Interv 2021;14: e009407.

    CrossrefMedlineGoogle Scholar
  • 13. Varc-3 Writing C., Genereux P., Piazza N., et al. "Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research". J Am Coll Cardiol 2021;77:2717-2746.

    View ArticleGoogle Scholar
  • 14. Genereux P., Demers P., Poulin F. "Same day discharge after transcatheter aortic valve replacement: Are we there yet?"Catheter Cardiovasc Interv 2016;87:980-982.

    CrossrefMedlineGoogle Scholar
  • 15. Rai D., Tahir M.W., Chowdhury M., et al. "Transcatheter aortic valve replacement same-day discharge for selected patients: a case series". Eur Heart J Case Rep 2021;5:ytaa556.

    CrossrefMedlineGoogle Scholar
  • 16. Russo M.J., Okoh A.K., Stump K., et al. "Safety and feasibility of same day discharge after transcatheter aortic valve replacement post COVID-19". Struct Heart 2021;5:182-185.

    CrossrefGoogle Scholar
  • 17. Perdoncin E., Greenbaum A.B., Grubb K.J., et al. "Safety of same-day discharge after uncomplicated, minimalist transcatheter aortic valve replacement in the COVID-19 era". Catheter Cardiovasc Interv 2021;97:940-947.

    CrossrefMedlineGoogle Scholar
  • 18. Fong T.G., Tulebaev S.R., Inouye S.K. "Delirium in elderly adults: diagnosis, prevention and treatment". Nat Rev Neurol 2009;5:210-220.

    CrossrefMedlineGoogle Scholar
  • 19. Bansal A., Saad A., Jain V., et al. "Delirium predicts worse outcomes in both transcatheter and surgical aortic valve replacement". J Am Coll Cardiol Intv 2021;14:1738-1740.

    View ArticleGoogle Scholar
  • 20. O'Connor S.A., Morice M.C., Gilard M., et al. "Revisiting sex equality with transcatheter aortic valve replacement outcomes: a collaborative, patient-level meta-analysis of 11,310 patients". J Am Coll Cardiol 2015;66:221-228.

    View ArticleGoogle Scholar
  • 21. Vlastra W., Chandrasekhar J., Garcia Del Blanco B., et al. "Sex differences in transfemoral transcatheter aortic valve replacement". J Am Coll Cardiol 2019;74:2758-2767.

    View ArticleGoogle Scholar
  • 22. Pighi M., Piazza N., Martucci G., et al. "Sex-specific determinants of outcomes after transcatheter aortic valve replacement". Circ Cardiovasc Qual Outcomes 2019;12: e005363.

    CrossrefMedlineGoogle Scholar
  • 23. Mazzella A.J., Hendrickson M.J., Arora S., et al. "Shifting trends in timing of pacemaker implantation after transcatheter aortic valve replacement". J Am Coll Cardiol Intv 2021;14:232-234.

    View ArticleGoogle Scholar
  • 24. Lilly S.M., Deshmukh A.J., Epstein A.E., et al. "2020 ACC Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement: a report of the American College of Cardiology Solution Set Oversight Committee". J Am Coll Cardiol 2020;76:2391-2411.

    View ArticleGoogle Scholar
  • 25. Rodes-Cabau J., Ellenbogen K.A., Krahn A.D., et al. "Management of conduction disturbances associated with transcatheter aortic valve replacement: JACC Scientific Expert Panel". J Am Coll Cardiol 2019;74:1086-1106.

    View ArticleGoogle Scholar
  • 26. Muntane-Carol G., Philippon F., Nault I., et al. "Ambulatory electrocardiogram monitoring in patients undergoing transcatheter aortic valve replacement: JACC State-of-the-Art Review". J Am Coll Cardiol 2021;77:1344-1356.

    View ArticleGoogle Scholar

Footnotes

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.