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
David A Wood, Sandra B Lauck, John A Cairns, Karin H Humphries, Richard Cook, Robert Welsh, Jonathon Leipsic, Philippe Genereux, Robert Moss, John Jue, Philipp Blanke, Anson Cheung, Jian Ye, Danny Dvir, Hamed Umedaly, Rael Klein, Kevin Rondi, Rohan Poulter, Dion Stub, Marco Barbanti, Peter Fahmy, Nay Htun, Dale Murdoch, Roshan Prakash, Madeleine Barker, Kevin Nickel, Jay Thakkar, Janarthanan Sathananthan, Ben Tyrell, Faisal Al-Qoofi, James L Velianou, Madhu K Natarajan, Harindra C Wijeysundera, Sam Radhakrishnan, Eric Horlick, Mark Osten, Christopher Buller, Mark Peterson, Anita Asgar, Donald Palisaitis, Jean-Bernard Masson, Susheel Kodali, Tamim Nazif, Vinod Thourani, Vasilis C Babaliaros, David J Cohen, Julie E Park, Martin B Leon, John G Webb, David A Wood, Sandra B Lauck, John A Cairns, Karin H Humphries, Richard Cook, Robert Welsh, Jonathon Leipsic, Philippe Genereux, Robert Moss, John Jue, Philipp Blanke, Anson Cheung, Jian Ye, Danny Dvir, Hamed Umedaly, Rael Klein, Kevin Rondi, Rohan Poulter, Dion Stub, Marco Barbanti, Peter Fahmy, Nay Htun, Dale Murdoch, Roshan Prakash, Madeleine Barker, Kevin Nickel, Jay Thakkar, Janarthanan Sathananthan, Ben Tyrell, Faisal Al-Qoofi, James L Velianou, Madhu K Natarajan, Harindra C Wijeysundera, Sam Radhakrishnan, Eric Horlick, Mark Osten, Christopher Buller, Mark Peterson, Anita Asgar, Donald Palisaitis, Jean-Bernard Masson, Susheel Kodali, Tamim Nazif, Vinod Thourani, Vasilis C Babaliaros, David J Cohen, Julie E Park, Martin B Leon, John G Webb
Abstract
Objectives: The authors sought to prospectively determine the safety and efficacy of next-day discharge using the Vancouver 3M (Multidisciplinary, Multimodality, but Minimalist) Clinical Pathway.
Background: Transfemoral transcatheter aortic valve replacement (TAVR) is an alternative to surgery in high- and intermediate-risk patients; however, hospital stays average at least 6 days in most trials. The Vancouver 3M Clinical Pathway is focused on next-day discharge, made possible by the use of objective screening criteria as well as streamlined peri- and post-procedural management guidelines.
Methods: Patients were enrolled from 6 low-volume (<100 TAVR/year), 4 medium-volume, and 3 high-volume (>200 TAVR/year) centers in Canada and the United States. The primary outcomes were a composite of all-cause death or stroke by 30 days and the proportion of patients successfully discharged home the day following TAVR.
Results: Of 1,400 screened patients, 411 were enrolled at 13 centers and received a SAPIEN XT (58.2%) or SAPIEN 3 (41.8%) valve (Edwards Lifesciences, Irvine, California). In centers enrolling exclusively in the study, 55% of screened patients were enrolled. The median age was 84 years (interquartile range: 78 to 87 years) with a median STS score of 4.9% (interquartile range: 3.3% to 6.8%). Next-day discharge home was achieved in 80.1% of patients, and within 48 h in 89.5%. The composite of all-cause mortality or stroke by 30 days occurred in 2.9% (95% confidence interval: 1.7% to 5.1%), with neither component of the primary outcome affected by hospital TAVR volume (p = 0.51). Secondary outcomes at 30 days included major vascular complication 2.4% (n = 10), readmission 9.2% (n = 36), cardiac readmission 5.7% (n = 22), new permanent pacemaker 5.7% (n = 23), and >mild paravalvular regurgitation 3.8% (n = 15).
Conclusions: Adherence to the Vancouver 3M Clinical Pathway at low-, medium-, and high-volume TAVR centers allows next-day discharge home with excellent safety and efficacy outcomes.
Keywords: clinical pathway; hospital volume; length of stay; next-day discharge; permanent pacemaker; procedural sedation; transcatheter aortic valve replacement.
Copyright © 2019. Published by Elsevier Inc.
Source: PubMed