Koren Ofir, Patel Vivek, Kohan Siamak, Naami Robert, Naami Edmund, Allison Zev, Natanzon Sharon Shalom, Shechter Alon, Nagasaka Takashi, Al Badri Ahmed, Devanabanda Arvind Reddy, Nakamura Mamoo, Cheng Wen, Jilaihawi Hasan, Makkar Raj R
Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States.
Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.
Front Cardiovasc Med. 2022 Oct 21;9:1022018. doi: 10.3389/fcvm.2022.1022018. eCollection 2022.
There is growing evidence of the safety of same-day discharge for low-risk conscious sedated TAVR patients. However, the evidence supporting the safety of early discharge following GA-TAVR with routine transesophageal echocardiography (TEE) is limited.
To assess the safety of early discharge following transcatheter aortic valve replacement (TAVR) using General Anesthesia (GA-TAVR) and identify predictors for patient selection.
We used data from 2,447 TEE-guided GA-TAVR patients performed at Cedars-Sinai between 2016 and 2021. Patients were categorized into three groups based on the discharge time from admission: 24 h, 24-48 h, and >48 h. Predictors for 30-day outcomes (cumulative adverse events and death) were validated on a matched cohort of 24 h vs. >24 h using the bootstrap model.
The >48 h group had significantly worse baseline cardiovascular profile, higher surgical risk, low functional status, and higher procedural complications than the 24 h and the 24-48 h groups. The rate of 30-day outcomes was significantly lower in the 24 h than the >48 h but did not differ from the 24-48 h (11.3 vs. 15.5 vs. 11.7%, = 0.003 and = 0.71, respectively). Independent poor prognostic factors of 30-day outcomes had a high STS risk of ≥8 (OR 1.90, 95% CI 1.30-2.77, -value = 3.2, < 0.001), low left ventricle ejection fraction of <30% (OR 6.0, 95% CI 3.96-9.10, -value = 11.5, < 0.001), and life-threatening procedural complications (OR 2.65, 95% CI 1.20-5.89, -value = 4.7, = 0.04). Our formulated predictors showed a good discrimination ability for patient selection (AUC: 0.78, 95% CI 0.75-0.81).
Discharge within 24 h following GA-TAVR using TEE is safe for selected patients using our proposed validated predictors.
越来越多的证据表明，低风险清醒镇静经导管主动脉瓣置换术（TAVR）患者当日出院是安全的。然而，支持全身麻醉下经导管主动脉瓣置换术（GA-TAVR）并常规行经食管超声心动图（TEE）检查后早期出院安全性的证据有限。
评估全身麻醉下经导管主动脉瓣置换术（GA-TAVR）后早期出院的安全性，并确定患者选择的预测因素。
我们使用了2016年至2021年在雪松西奈医疗中心进行的2447例TEE引导下GA-TAVR患者的数据。根据入院后出院时间将患者分为三组：24小时、24至48小时和>48小时。使用自举模型在24小时与>24小时的匹配队列中验证30天结局（累积不良事件和死亡）的预测因素。
与24小时组和24至48小时组相比，>48小时组的基线心血管状况明显更差，手术风险更高，功能状态低下，手术并发症更多。24小时组的30天结局发生率明显低于>48小时组，但与24至48小时组无差异（分别为11.3%、15.5%和11.7%，P = 0.003和P = 0.71）。30天结局的独立不良预后因素包括高危外科医生协会（STS）风险≥8（比值比1.90，95%置信区间1.30 - 2.77，P值 = 3.2，P < 0.001）、左心室射血分数<30%（比值比6.0，95%置信区间3.96 - 9.10，P值 = 11.5，P < 0.001）以及危及生命的手术并发症（比值比2.65，95%置信区间1.20 - 5.89，P值 = 4.7，P = 0.04）。我们制定的预测因素对患者选择具有良好的鉴别能力（曲线下面积：0.78，95%置信区间0.75 - 0.81）。
对于使用我们提出并经验证的预测因素选择出的患者，TEE引导下GA-TAVR术后24小时内出院是安全的。
