Maggie McKay (Host): When having surgery, especially heart surgery, many patients are anxious about having to stay in the hospital for a long period of time. But that scenario is changing. Today, we'll find out about protocol changes that facilitate outpatient-based procedures the win-win for patients and clinicians. Joining us to discuss this exciting option is Dr. Andrei Pop, an Interventional Cardiologist and Structural Director at Ascension Illinois -- and also serves as Medical Director of the Cardiac Cath Lab at Ascension Alexian Brothers Medical Center.

Welcome to HealthCast, the podcast from Ascension Illinois - I'm your host, Maggie McKay. Dr. Pop, please tell us about same-day discharge, Taver,

Andrei Pop, MD (Guest): Thank you for having me. It's a pleasure to be here.

Host: First of all, what does TAVR stand for and what is the procedure?

Dr. Pop: So, TAVR is a procedure for minimally invasive replacement of the aortic valve. TAVR stands for transcatheter aortic valve replacement. And it is a procedure through which we replace the aortic valve without the need to open the chest, in the vast majority of patients. In most cases, we're able to do this through a very small incision in the groin, through which we advance a catheter that contains the valve that is placed in the patient's heart.

Host: How long does the valve last?

Dr. Pop: That is a very good question. The valve has only commercially been available for 10 years. The first procedure in the United States was less than 16 years ago. And, we think that in most people, the longevity of the valve is similar to the longevity of a surgical valve, which these days is somewhere between 10 and 20 years.

Host: So, do they have to stop your heart during the procedure?

Dr. Pop: The heart is not technically speaking stopped, but we do pace the heart. Meaning we cause the heart to beat extremely fast. We aim for 180 beats a minute, which basically creates essentially cardiac standstill for a very short period of time, during which time we're able to deploy the valve.

Host: So, the structural heart program at Ascension Alexian Brothers Medical Center, Elk Grove Village implemented same-day discharge TAVR protocols in June, 2020. Could you tell us what led your team to move from so-called early discharge to same-day discharge?

Dr. Pop: So, starting in early 2020, we became part of a program, called Benchmark, which is a program for optimizing TAVR procedures. We met with faculty from this program in February. And we completed our program in record time, as the pandemic was happening. We had already been discharging the majority of our patients within 24 hours of the procedure, but adopting best practices from the program allowed us to do this in a more predictable fashion. And allowed us to basically, get the best outcomes possible. However, as soon as we implemented these best practices, COVID happened. And by late March, we were thinking of stopping elective procedures. And even though TAVR is, in most cases, not a purely elective procedure, we knew that we were coming up to a period when procedures will be difficult to do due to limitations caused by COVID.

During the period when hospitals where essentially overwhelmed by COVID, in Illinois between April and June of 2020, most of our staff was dispatched to other areas of the hospital because we did not do elective procedures in the Cardiac Cath Lab. And we chose to have our staff go to the intensive care unit and acquire new skills while they were there. By the time we gradually resumed elective procedures, our staff had received the extensive training in the intensive care unit. And we had developed this protocol for basically offering to patients who qualify, the opportunity to be discharged the same day after their aortic valve replacement.

There had been a few case reports of this being done. But, there was not really a universally agreed protocol to do this. We did extensive research in looking at various factors that would predict patients who would have complications. And we devised what we consider to be a very conservative protocol, which identified a minority of patients that would be offered same-day discharge. Probably around 20% of the patients would qualify for same-day discharge. And, not every single one of them ended up being discharged same-day.

Host: And how does a person qualify for it? If they're high risk, low risk for the same-day discharge?

Dr. Pop: So, what we did is, we looked at patient characteristics that would predict complications within the first 24 hours, because basically, what we know is that in geriatric patients, in particular, in older patients, the more you stay in the hospital, the more trouble you get into. So, it's already been established that the vast majority of patients can go home at 24 hours. So, our task was really to identify patients who would be at high risk of complications or any risk of complications within the first 24 hours. Since the majority of patients are going home in 24 hours, we were trying to identify a subset of the patients that would be able to go home earlier, at eight hours.

And basically, patients who qualified for this approach where patients who first of all, had resources at home, had family members at home who would be able to stay with them overnight and help them in case there were problems, patients who lived within a reasonable distance of our facility, so they could return it or any problems. But most importantly, patients who had no electrical abnormalities of the heart. And the reason for this is that when you put a valve in the aorta, an aortic valve, there is always a risk of causing conduction system abnormalities. Meaning the electrical system of the heart can become more sluggish after valve implantation.

That is something that happens with surgical valves. That is something that happens with transcatheter valves. And there are very clearly identified risk factors for this to happen. So, any patient who had any pre-existing abnormalities on their electrocardiogram, any patients would develop any abnormalities, even transient abnormalities after the valve implantation, was excluded because we wanted to watch those patients overnight and make sure that nothing happened that would lead to them to requiring a pacemaker. In doing this, we were very conservative, perhaps more conservative than necessary, but we wanted to be very safe.

Host: Do you ever have a patient who does qualify to go home the same-day say, oh, no way, I want to stay in the hospital as long as possible. What happens then?

Dr. Pop: Well, we've had patients who don't want to go home or their families don't feel comfortable taking them home. And in those cases, they get to stay. They stay overnight. And, so we certainly don't have this discussion the day of procedure. The discussions starts the moment we see the patient in clinic. When we see patients in clinic, they are generally accompanied by several family members. And, we discuss all these aspects and we make sure that they have resources at home to have them be well taken care of after 24 hours and if necessary within 24 hours and to some patients, we say, you know what, you're probably going to have to spend more days in the hospital. To some patients we say most likely you will go home within 24 hours. And to other patients, we say there is a chance that if everything goes well with your procedure and you have no problems and your electrocardiogram stays as good it is now, we will offer you a discharge within 24 hours. In the end the patients and the family makes the ultimate decision, because this is a relatively early stage of this protocol. We would never force anybody to go. We offer this as an option and a lot of patients have chosen to avail themselves of this, especially in the context of the continuing COVID pandemic.

Host: So to date, Dr. Pop, how many same day discharge cases has the program completed and what are the outcomes generally? What's the success rate?

Dr. Pop: We've had close to 70 patients. I think we're at 68, perhaps 69 right now that have been discharged the same day. Not a single one of them has returned to the hospital within 24 hours. We've had a couple people who had issues later, within a month of the procedure, but what makes me feel good is that none of the issues that occurred later would have been prevented by a longer hospital stay. Also most important to me, none of the patients that were treated as part of this protocol have gotten COVID while they were in the hospital, which is something that especially very early on, but also right now, a lot of people are terrified of.

Host: Of course. What do you feel the key to the success of your program is?

Dr. Pop: I think it's we started very conservatively and we stayed very conservative. We have to have complete buy-in from the entire team, and I can't overemphasize the importance of the team participation in this. Same-day discharge is not something that I do or anybody else does. This is something that has to be agreed by every single member of our team and in structural heart disease, we are not only mandated to have a team approach, but it's something that we believe strongly in. And, part of the criteria for same-day discharge is that every single team member involved in the care of the patient is in agreement that the patient can be discharged the same day. The family's in agreement, the patient is in agreement.

We rely a lot on our nurses. Part of the COVID protocol we've put in place, we try to have a single nurse taking care of the patient before and after the procedure, patient stays in a single room, does not go from room to room or does not go in various areas of the hospital. And so that nurse knows the patient intimately and they know him.

They've seen him walking in a hospital. They see him walking after the procedure, they see how they're doing. And if that nurse is not comfortable, they can say no, patient needs to stay overnight. And we never overrule any single member of our team because everybody is critical to making the best decision for the patient.

Host: Of course. It's my understanding that the protocol was adopted as part of the international registry of patients and presented at the premier interventional conference called TCT this year. How far are we from same-day TAVR being the recommended clinical guideline?

Dr. Pop: So, I think the recommendations in medicine are a lot of times driven by randomized studies. So, randomized studies mean that you select a group of patients and then essentially a computer chooses which patients go home and which patients stay. That is something that I'm not sure is going to happen in the near future, because that is quite resource intensive.

And, I think right now, we're all focusing on delivering the best care we can, in the context of the COVID imposed limitations. But that being said, the closest thing to a randomized clinical trial are good quality registries. And this is what we have done with this Protect TAVR protocol, which was put together, by us together with the University of British Columbia and Emory University in Atlanta, as well as several other international sites where a protocol, very similar to the one that we designed, was used for evaluating the outcomes of more than 120 patients who underwent same-day discharge, as I said at multiple international sites. The results of the protocol, the preliminary results with the protocol were presented at TCT, which is indeed the premiere interventional cardiology conference. And a couple of days ago, our full publication was accepted for publication in the Journal of the American College of Cardiology.

So, I think, multiple other groups are looking at this around the world. We're trying to assemble a large enough data set that will agree on essentially a protocol and agree on a set of requirements for these patients, that will allow this to become part of the standard of care or the mainstream.

Host: That's exciting. Dr. Pop in closing, do you have any additional thoughts or information to add for patients who are considering same-day discharge?

Dr. Pop: I think it's something that we're proud and happy to offer to selected patients. I would say that it's something that we always tell patients that we're not going to know for sure whether they'll qualify until the moment they leave the hospital. It's never something that we rely on. It's something that we hope to be able to offer to select patients. And as I said, perhaps up to 20% of patients are preliminarily considered for same-day discharge and in our experience so far, we're somewhere between 17, 18% of our patients have gone home the same day since we started the program.

The other thing that I'll say is that in parallel with this, we have developed a special unit where our patients come before procedures, stay after procedure and go home from, whether same-day or next day. And that has allowed us to continue to function despite the limitations imposed by the pandemic. And we've been able to help quite a number of people in this period. And we are again, quite proud that nobody has been affected with COVID, in the hospital. And we've been able to offer a safe environment for these patients to have their procedures.

Host: Absolutely. Well congratulations on all its success. And especially like you just mentioned on no patients contracting COVID while they were in the hospital. I appreciate you sharing your knowledge with us and your time. This is HealthCast, the podcast from Ascension Illinois. I'm Maggie McKay. For more information, you can visit ascension.org/ILheartvalvecare [Ascension dot org slash I-L heart valve care]. Thank you for listening.