Impact of ERAS protocol in nonagenarians undergoing TAVR

Background
Despite improvements in surgical technique, anesthesia, and perioperative care, nonagenarians have significant morbidity and prolonged length of stay (LOS) after transcatheter aortic valve replacement (TAVR). Enhanced recovery after surgery (ERAS) is a multimodal perioperative care that decreases postoperative morbidity. The data on using ERAS in nonagenarians undergoing TAVR is limited.

Methods:
This is a retrospective cohort study of nonagenarians (Age 90-99) that underwent TAVR between 04-2012 and 12-2016 in a tertiary cardiovascular center. Ten points of ERAS protocol were assessed. Evaluated outcomes included: LOS, in-hospital infections, acute kidney injury (AKI), 30-day, and 1-year mortality.

Results
A total of 572 patients underwent TAVR in our institution. ERAS protocol was evaluated in 93 nonagenarians, of which 45(48%) were female with a mean age of 92 ± 2 years and mean STS score of 8.5 ± 4.8. Hypertension and diabetes mellitus were present in 73 (78%) and 18 (19%) of patients, respectively. Mean aortic valve area was 0.6 ± 0.18 cm2 and mean AV-gradient was 51.8 ± 13.1 mmHg. Outcomes: See table 1 for the ERAS protocol. The mean LOS for patients with optimal ERAS was 5.9± 3.5 days vs. 8.12 ±4.0 for non-optimal ERAS (p-value 0.011). For every incremental point in ERAS, LOS decreased 0.58 days (p-value <0.0001). There was no association between ERAS and in-hospital infections (p-value 0.759), AKI (p-value 0.131), 30-day mortality (0.510) and 1-year mortality (0.511).

Conclusions
This study suggests that implementation of ERAS protocol in nonagenarians undergoing TAVR decreases LOS, but does not affect short or long term-mortality