Enhanced recovery after surgery (ERAS) protocols have proven effective in a variety of surgical specialties. Published reports on these pathways within cardiac surgery and interventional cardiology are limited. Invasive aortic valve replacement procedures are increasingly being performed by hybrid groups of interventional cardiologists and surgeons through transcatheter aortic valve implantation (TAVI). The TAVI patient population is at a higher surgical risk compared with those undergoing surgical aortic valve replacement since they are older, frailer, and have significant co-morbidities which result in an increased risk of perioperative complications. ERAS protocols have the potential to help these patients undergoing TAVI procedures. In conclusion, we propose a TAVI ERAS protocol with a call-to-action for other centers to implement an ERAS protocol to improve hospital and cardiac outcomes.
Enhanced recovery after surgery (ERAS) clinical pathways have been shown to decrease complications in various surgical fields but have not been tested in the population undergoing percutaneous valve therapies. ERAS pathways serve as a framework for comprehensive multidisciplinary perioperative care that include evidence-based, best practice recommendations for preoperative, intraoperative, and postoperative management. Led by a dedicated multidisciplinary team of cardiologists, surgeons, anesthesiologists, advanced practice providers, and nurses, our institution designed and implemented an ERAS clinical pathway for patients undergoing transcatheter aortic valve implantation (TAVI). Herein, we describe our ERAS clinical pathway, describe our beliefs and goals for the program, share a framework that can be adopted at other institutions, and encourage others to join in implementing similar ERAS pathways for TAVI that provide these complex patients the highest likelihood of a successful recovery.
The goals of a traditional ERAS clinical pathway are (1) to accelerate patient recovery and (2) maintain normal homeostasis through application of evidence-based, best practice guidelines. The core components of ERAS clinical pathways include preoperative patient optimization and education, multimodal opioid-sparing analgesia, standardized intraoperative anesthetic management, and postoperative systems of care to limit immobility and nosocomial infection risk. ERAS clinical pathways have been developed for a variety of different surgical specialties. These pathways have demonstrated a variety of improved clinical outcomes including decreased hospital length of stay, improved pain management, and decreased surgical site and urinary tract infections.
Although there has been significant research on ERAS clinical pathways for traditional surgical procedures, research is lacking on how the principles of ERAS could be applied to cardiac surgery and hybrid cardiovascular procedures, including TAVI. This is particularly important as the population of patients presenting for TAVI are often older, frailer, with multiple co-morbidities, and are at an elevated risk for perioperative complications.
The aortic stenosis patient population
Severe calcific aortic stenosis is a common valvular disease with a prevalence of 3.4% in the population over 75 years old. This age group is expected to grow from 6.1% in 2010 to 8.9% of the total US population by 2030. Many of these patients are at higher risk, or even prohibitive risk, for traditional open heart surgery due to the increased risk of perioperative complications related to advanced age, frailty, and significant co-morbidities. Postoperative complications, including renal and pulmonary complications are common in this patient population. Furthermore, elderly patients with high surgical risk can encounter postoperative delirium up to 53% of the time depending on the type of the surgery and up to 70% to 87% if an intensive care unit (ICU) admission is necessary. TAVI has been developed to address the difficulties of treating severe aortic stenosis, particularly in patients considered high risk for surgery. Historically, TAVI has had similar postsurgical risks to surgical aortic valve replacement (AVR). However, with the newest generation of transcatheter valves, TAVI is shown to reduce postsurgical complications, including reducing the risk of acute kidney injury (AKI) to 6.2% compared to 15.1% with surgical AVR. Furthermore, recent clinical trial data have shown that TAVI is associated with lower all-cause mortality compared with surgical AVR in patients who are deemed high risk for surgery (3% vs 5% at 30 days, 14% vs 19% at 1 year, and 22% vs 29% at 2 years, respectively). As a result, TAVI has become the preferred method of AVR in those deemed at high risk for an open surgical procedure.
Supported by these data, many more patients at high and extreme risk for surgery are now coming to the operating room for transcatheter approaches to AVR. Therefore, the need to care for these patients in a systematic manner that incorporates many of the proved principles of ERAS is growing at a rapid pace. ERAS clinical pathways could help minimize the risk of significant postoperative complications for the TAVI patient population such as postoperative delirium, postoperative cognitive dysfunction, pneumonia, deep venous thrombosis, urinary tract infection, and postoperative functional decline.
Current Challenges Defined
Patients with symptomatic aortic stenosis who may be candidates for TAVI tend to be older, frail, malnourished, and physically deconditioned from activity intolerance secondary to debilitating symptoms. Due to their age, nutritional status, and co-morbidities, these patients are frequently too high risk for surgical AVR. Co-morbidities, including preoperative renal dysfunction and pulmonary dysfunction, are more prevalent in this older population and have been shown to increase mortality after surgery. This combination of factors often results in delayed functional recovery and difficulty returning to normal daily activities after valve implantation.
Increased frailty status is associated with an increase in 1-year mortality after TAVI. Poor preoperative nutritional status occurs in approximately 10% to 25% of cardiac surgery patients and has been shown to increase hospital stay as well as negatively impact patient outcomes. Elderly patients tend to remain protein deficient throughout the perioperative period which is shown to be an independent risk factor for increased mortality in the elderly population.
Postoperative delirium has been shown to significantly impact patient recovery and delay hospital discharge across all surgical specialties, including TAVI. The risk factors for postoperative delirium include advanced age, preexisting dementia, general anesthesia, and perioperative use of benzodiazepines and opioids. As such, intraoperative anesthetic technique and drug selection becomes paramount for prevention of postoperative delirium.
Other intraoperative issues for TAVI center on dynamic changes in hemodynamics related to valve positioning and deployment. Periods of hypotension (even brief) may pose increased risk for stroke and myocardial ischemia. Embolization of calcium during valve deployment may also lead to stroke and myocardial ischemia.
Pain management is crucial to promote early ambulation and to prevent postoperative complications such as pneumonia and deep venous thrombosis. Uncontrolled pain after any surgical procedure is associated with longer hospital length of stay, delayed ambulation, and poorer outcomes. TAVI has several valve delivery approaches including transfemoral, transapical, subclavian, suprasternal, and transaortic, which represent a varying intensity of postsurgical pain. The technical aspects of transfemoral TAVI have advanced and percutaneous techniques and smaller delivery systems have decreased the need for surgical cutdowns to expose the femoral vessels. This has helped improve perioperative pain control for this particular subset of patients undergoing TAVI. However, the transapical approach to TAVI necessitates an anterior thoracotomy, which is much more painful. The pain associated with an anterior thoracotomy incision for a transapical TAVI poses significant risk of postoperative pulmonary complications including atelectasis, pneumonia, and respiratory failure. As such, studies have shown a 30-day all-cause mortality for the transapical approach to be >9%. Although opioids have been the mainstay of postsurgical analgesia, side effects such as delirium, nausea, vomiting, and constipation are often seen, especially in the elderly population.
Patients undergoing TAVI are also at increased risk for postoperative AKI. AKI after percutaneous coronary interventions has been shown to increase postprocedural mortality. An increase in creatinine of 0.3 mg/dl from baseline after TAVI has been shown to have a worse prognosis, including increased ICU time, in-hospital mortality, and 30-day mortality.
Prolonged immobilization for postsurgical elderly patients may lead to skin breakdown, vasomotor instability, decline in respiratory function, urinary incontinence, and other functional complications. Early mobilization after surgery can decrease the risk of pneumonia, postsurgical delirium, and ileus. In addition, patients more quickly recover the ability to perform activities of daily living with timely postsurgical mobilization which has been shown to help decrease hospital length of stay.
Table 1 outlines the framework of our ERAS protocol. It involves interventions in the preoperative, intraoperative, and postoperative phases of care. A focus on nutrition, mobilization, physical therapy, and enhancing respiratory function all comprise the components of the preoperative protocol. Intraoperative management is largely led by the team of cardiac anesthesiologists who employ the use of short-acting anesthetics to decrease the likelihood of delirium and allow for early functional recovery. The postoperative care focuses on early ambulation, removal of hemodynamic monitors as soon as possible, a focus on nutrition and bowel/urinary function, and opioid-sparing analgesia.
| Enhanced Recovery after Surgery (ERAS) Protocol – Overview | |
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| Pre-Operative |
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| Intra-Operative |
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| Post-Operative |
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Current Challenges Defined
Patients with symptomatic aortic stenosis who may be candidates for TAVI tend to be older, frail, malnourished, and physically deconditioned from activity intolerance secondary to debilitating symptoms. Due to their age, nutritional status, and co-morbidities, these patients are frequently too high risk for surgical AVR. Co-morbidities, including preoperative renal dysfunction and pulmonary dysfunction, are more prevalent in this older population and have been shown to increase mortality after surgery. This combination of factors often results in delayed functional recovery and difficulty returning to normal daily activities after valve implantation.
Increased frailty status is associated with an increase in 1-year mortality after TAVI. Poor preoperative nutritional status occurs in approximately 10% to 25% of cardiac surgery patients and has been shown to increase hospital stay as well as negatively impact patient outcomes. Elderly patients tend to remain protein deficient throughout the perioperative period which is shown to be an independent risk factor for increased mortality in the elderly population.
Postoperative delirium has been shown to significantly impact patient recovery and delay hospital discharge across all surgical specialties, including TAVI. The risk factors for postoperative delirium include advanced age, preexisting dementia, general anesthesia, and perioperative use of benzodiazepines and opioids. As such, intraoperative anesthetic technique and drug selection becomes paramount for prevention of postoperative delirium.
Other intraoperative issues for TAVI center on dynamic changes in hemodynamics related to valve positioning and deployment. Periods of hypotension (even brief) may pose increased risk for stroke and myocardial ischemia. Embolization of calcium during valve deployment may also lead to stroke and myocardial ischemia.
Pain management is crucial to promote early ambulation and to prevent postoperative complications such as pneumonia and deep venous thrombosis. Uncontrolled pain after any surgical procedure is associated with longer hospital length of stay, delayed ambulation, and poorer outcomes. TAVI has several valve delivery approaches including transfemoral, transapical, subclavian, suprasternal, and transaortic, which represent a varying intensity of postsurgical pain. The technical aspects of transfemoral TAVI have advanced and percutaneous techniques and smaller delivery systems have decreased the need for surgical cutdowns to expose the femoral vessels. This has helped improve perioperative pain control for this particular subset of patients undergoing TAVI. However, the transapical approach to TAVI necessitates an anterior thoracotomy, which is much more painful. The pain associated with an anterior thoracotomy incision for a transapical TAVI poses significant risk of postoperative pulmonary complications including atelectasis, pneumonia, and respiratory failure. As such, studies have shown a 30-day all-cause mortality for the transapical approach to be >9%. Although opioids have been the mainstay of postsurgical analgesia, side effects such as delirium, nausea, vomiting, and constipation are often seen, especially in the elderly population.
Patients undergoing TAVI are also at increased risk for postoperative AKI. AKI after percutaneous coronary interventions has been shown to increase postprocedural mortality. An increase in creatinine of 0.3 mg/dl from baseline after TAVI has been shown to have a worse prognosis, including increased ICU time, in-hospital mortality, and 30-day mortality.
Prolonged immobilization for postsurgical elderly patients may lead to skin breakdown, vasomotor instability, decline in respiratory function, urinary incontinence, and other functional complications. Early mobilization after surgery can decrease the risk of pneumonia, postsurgical delirium, and ileus. In addition, patients more quickly recover the ability to perform activities of daily living with timely postsurgical mobilization which has been shown to help decrease hospital length of stay.
Table 1 outlines the framework of our ERAS protocol. It involves interventions in the preoperative, intraoperative, and postoperative phases of care. A focus on nutrition, mobilization, physical therapy, and enhancing respiratory function all comprise the components of the preoperative protocol. Intraoperative management is largely led by the team of cardiac anesthesiologists who employ the use of short-acting anesthetics to decrease the likelihood of delirium and allow for early functional recovery. The postoperative care focuses on early ambulation, removal of hemodynamic monitors as soon as possible, a focus on nutrition and bowel/urinary function, and opioid-sparing analgesia.
