Abstract-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. Goals and Vision of the ProgramTranscatheter aortic valve replacement (TAVR) is a recommended treatment for inoperable and select higher surgical risk patients with severe aortic stenosis. [1][2][3] In the first decade of therapy development, careful case selection, increased periprocedural expertise, and enhanced technology have contributed to improved outcomes and patient access to TAVR. 4,5 Interest is shifting from "How we do TAVR" to "How we care for TAVR patients" to further optimize outcomes, reduce health service utilization, and contribute to the sustained success of transcatheter heart valve therapies. 6 Duration of hospital stay is an indicator of quality of care and a predictor of outcome in the elderly population. 7 There is a significant variation in reported postprocedure length of stay (LOS) after TAVR, ranging from 1 to >10 days.8-10 Similar variation exists in patients' disposition at the time of discharge; for example, the US Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry reported i...

Background The long‐term clinical performance of transcatheter heart valves (THV) is unknown. Aims This study assessed the clinical outcomes, rate of structural valve deterioration (SVD) and bioprosthetic valve failure in patients after transcatheter aortic valve replacement (TAVR) to 10‐year follow‐up. Methods Consecutive patients undergoing TAVI for native aortic valve stenosis or failed aortic surgical bioprosthesis, between 2005 and 2009 at our institution were included. A total of 235 consecutive patients. Results At the time of TAVI mean age was 82.4 ± 7.9 years. All patients were judged to be high risk, with a STS score > 8 in 53.6%. THVs implanted were the Cribier‐Edwards (20.9%), Edwards SAPIEN (77.4%) or CoreValve (1.7%). Mortality at 1, 5, and 10‐year follow‐up was 23.4%, 63%, and 91.6%, respectively. Of the total cohort, 15 patients had structural valve deterioration/bioprosthetic valve failure, with a cumulative incidence at 10‐years of 6.5% (95% CI 3.3%, 9.6%). The rate of SVD/BVF at 4, 6, 8, and 10 years was 0.4%, 1.7%, 4.7%, and 6.5%, respectively. Nine patients had moderate SVD and six patients had severe SVD. Of the six patients with severe SVD, two patients had reintervention (one patient had redo TAVR, and the second had surgical aortic valve replacement). Survivors (n = 19) at 10‐year follow‐up, had a mean gradient of 14.0 ± 7.6 mmHg and aortic regurgitation ≥moderate in 5%. Quality of life measures in 10‐year survivors demonstrated ADLs 6/6 in 43.8%, and ambulation without a mobility aid of 62.5%. Conclusion Using early generation balloon expandable THVs in a high‐risk population, there was a low rate of structural valve deterioration and valve failure at 10‐year follow‐up. This study provides insights into the long‐term performance of transcatheter heart valves and patients self‐reported derived benefits.