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Page 2 of 11 van Wiechen et al. Mini-invasive Surg 2022;6:1 https://dx.doi.org/10.20517/2574-1225.2021.96

Conclusion: Early discharge pathways home and to referral hospitals are safe and help streamline TAVI programs.
LOS in referring hospitals may be further reduced.

Keywords: Aortic valve stenosis, transcatheter aortic valve implantation, early discharge, length of stay

INTRODUCTION
Severe aortic stenosis is the most common valve disease requiring treatment in the Western world, and its
[1]
prevalence is growing due to an ageing population . The only curative option for aortic stenosis is surgical
or transcatheter valve implantation. Transcatheter aortic valve implantation (TAVI) is indicated for patients
[2,3]
with a high or intermediate surgical risk . Recent trials have also shown TAVI feasibility in low surgical
risk patients . Every patient requiring a bioprosthesis for aortic stenosis should now be informed about the
[4,5]
transcatheter option.

As a result, the European and North American annual TAVI volume is expected to increase from 180,000 to
270,000 cases per year . Contemporary society guidelines recommend centralizing TAVI care in high-
[6]
[7]
volume (> 85 procedures/year) sites because of an inverse volume-mortality correlation . To reconcile
TAVI demand and supply and maintain high-quality healthcare at an affordable price, high-volume centers
need to modify the TAVI cascade and streamline discharge policy. Early home discharge protocols aim to
limit in-hospital stay to fewer than three days after TAVI with favorable early and mid-term outcomes and
[8]
no penalty for readmissions or delayed need for definite pacemakers .
For this purpose, we installed the TAVI EXpedited discharge Program Rotterdam EraSmus MC (TAVI
EXPRES) and TAVI referral-EXPRES (TAVI R-EXPRES) programs in our institution. Various
characteristics specific to the individual patient, the procedure, and the post-procedural recovery determine
early discharge eligibility, either home or to a referring hospital. Early discharge protocols have been
described, but thus far involvement of referring hospitals in the TAVI cascade has not been specifically
studied [9,10] .

Early discharge to referring hospitals could optimize patient flow and bring post procedural quality care
closer to (elderly) patients’ home environment. The R-EXPRES program is a collaboration between the
Erasmus MC and referring hospitals to organize patient work up before and care after TAVI in the referring
hospital.

Herein, we report on the Rotterdam approach to promote early discharge home or to a referring hospital in
the perspective of contemporary clinical practice and compare 30-day outcomes in different discharge
pathways.

METHODS
Study population
All patients who underwent TAVI at the Erasmus MC between July 2017 and July 2019 and had complete
30-day follow-up were included. Patients were further identified in the TAVI EXpedited discharge Program
Rotterdam Erasmus MC (EXPRES) and the referral EXPRES (R-EXPRES) program.

Patients who were deemed eligible for the EXPRES program were earmarked in the outpatient clinic by
TAVI operators based on clinical criteria [Table 1]. These patients were then approached by a TAVI
coordinating nurse who explained the “early discharge” concept, confirmed adequate social/familial