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Despite the high procedural success of transcatheter aortic valve replacement (TAVR), 2 out of 5 older adults report poor physical performance and health-related quality of life (HRQOL) in the ensuing months, particularly those with frailty. There has yet to be a trial examining the synergistic effects of exercise and protein supplementation to counteract frailty and improve patient-centred outcomes following TAVR. The PERFORM-TAVR trial is a multicentre parallel-group randomised clinical trial that is enrolling 200 frail older adults ≥ 70 years of age undergoing TAVR. Patients will be randomly allocated to 1 of 2 treatment groups: standard-of-care lifestyle education (control group) or protein-rich oral nutritional supplement for 4 weeks before TAVR with the addition of home-based supervised exercise sessions for 12 weeks after TAVR (intervention group). The primary outcome will be physical performance as measured by a blinded observer using the Short Physical Performance Battery at 3 months. Secondary outcomes at 3, 6, and 12 months will include HRQOL, as measured by the Short-Form 36 Physical and Mental Component summary scores, and a composite safety end point. The PERFORM-TAVR trial is testing a novel frailty intervention in older adults undergoing TAVR to optimise recovery and downstream HRQOL. This represents a potential paradigm shift that highlights the value of assessing and treating patients’ frailty in parallel with their underlying heart valve disease.

The current coronavirus disease 2019 (COVID-19) pandemic is creating unprecedented and unchartered demands on critical care units to meet patient needs and adapt the delivery of health services. Critical care nurses play a pivotal role in developing models of care that are effective, flexible, and safe.

ABSTRACTBackground:We assessed the safety and efficacy of a clinical pathway with transfemoral transcatheter aortic valve replacement (TAVR) performed in the catheterization laboratory, accelerated recovery on a general cardiology ward and early discharge.Methods:The Vancouver accelerated recovery clinical pathway is an initiative with aims to implement (1) multidisciplinary team selection of patients with lower TAVR procedural risk; (2) peri-procedural minimalist approach with minimal procedural sedation; (3) pre-specified criteria for accelerated transfer to a general cardiology ward; (4) rapid reconditioning post-procedural care; and (5) identification of patients suitable for early (<48 hours) discharge home.Results:A total of 100 prospective patients underwent TAVR with the Vancouver accelerated recovery pathway between September 2016 and August 2018 with a mean age of 79.4 ± 7.4 years and Society of Thoracic Surgeons (STS) score of 3.5 ± 1.7 (55% had STS≥3). Only one (1%) patient needed conversion to general anesthesia, two (2%) patients needed urgent pacemaker implantation for conduction disorder, one (1%) patient had a stroke and five (5%) patients had minor vascular complications. All patients were transferred to the ward but one (1%) patient subsequently needed escalation of care to the coronary care unit. Mean time to first mobilization was 267 ± 60 minutes. Overall, 87 (87%) patients achieved next day discharge and 97 (97%) patients were discharged ≤48 hours. The 30-day mortality was 1% and all-cause readmission rate was 5%.Conclusion:Use of the Vancouver accelerated recovery pathway in highly-selected patients allows TAVR to be performed in the catheterization laboratory followed by accelerated recovery to the ward, with minimal mortality, morbidity, and a high proportion of early discharge. As TAVR continues to expand, this has important implications for health care delivery.

Patients who have had transcatheter aortic valve replacement (TAVR) are at risk of hospitalization during the first year postprocedure. Few studies have examined the incidence of heart- failure hospitalizations (HFH) post-TAVR and the impact this has on subsequent hospitalizations and mortality. Our aim was to determine the incidence, predictors, and mortality associated with HFH post-TAVR.

Transcatheter aortic valve replacement (TAVR) can cause injury to the atrioventricular conduction system. We evaluated the effect of transcatheter heart valve (THV) type on the rate of new pacemaker implantation and length of hospital stay.

We describe the development, implementation, and evaluation of a standardized clinical pathway to facilitate safe discharge home at the earliest time after transfemoral transcatheter aortic valve replacement. Between May 2012 and October 2014, the Heart Team developed a clinical pathway suited to the unique requirements of transfemoral transcatheter aortic valve replacement in contemporary practice. The components included risk-stratified minimalist periprocedure approach, standardized postprocedure care with early mobilization and reconditioning, and criteria-driven discharge home. Our aim was to reduce variation in care, identify a subgroup of patients suitable for early discharge (≤48 hours), and decrease length of stay for all patients. We addressed barriers related to historical practices, complex multidisciplinary stakeholder engagement, and adoption of length of stay as a quality indicator. We retrospectively reviewed the experiences of 393 consecutive patients; 150 (38.2%) were discharged early. At baseline, early discharge patients had experienced less previous balloon aortic valvuloplasty, had higher left ventricular ejection fraction, better cognitive function, and were less frail than the standard discharge group (>48 hours). Early discharge was associated with the use of local anesthesia, implantation of balloon expandable device, avoidance of urinary catheter, and early removal of temporary pacemaker. Median length of stay was 1 day for early discharge and 3 days for other patients; 97.7% were discharged home. There were no differences in 30-day mortality (1.3%), disabling stroke (0.8%), or readmission (10.7%). The implementation of a transcatheter aortic valve replacement clinical pathway shifted the program’s approach to combine standardized processes and individual risk stratification. The Vancouver transcatheter aortic valve replacement clinical pathway requires a rigorous assessment to determine its efficacy, safety, and reproducibility.