Clinical outcome in nonagenarians undergoing transcatheter valve replacement

Abstract

BackgroundNonagenarians are mostly denied from different therapeutic strategies due to high preoperative risk. We present the results of nonagenarians with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).MethodsOur retrospective analysis include baseline and procedural data along with clinical outcome. Clinical follow-up was performed in all patients after TAVR.ResultsOut of 689 patients, 33 nonagenarians with a mean age of 90.9 ± 1.4 years suffering from severe AS and elevated comorbidity index (logistic EuroSCORE of 16.3 ± 9.6%, STS score 11.1 ± 9.9%) underwent TAVR between September 2009 and July 2016 using self-expanding prosthesis. Baseline transthoracic echocardiography reported a mean aortic valve area (AVA) of 0.64 ± 0.12 cm2 with a mean pressure gradient of 56.1 ± 16.1 mmHg. Five (16.2%) patients had postprocedural moderate/severe aortic regurgitation. One patient died intraoperally due to ventricular perforation during predilatation, while two patients died within the first 30 days, one due to cardiogenic shock and the other due to pneumonia. No patient experienced a myocardial infarction or a stroke, while ten (30.3%) required permanent pacemaker placement. At follow-up (mean 20.3 months, range 1–78 months), all cause and cardiovascular mortality was 24.2% and 15.1%, respectively. Two patients presented heart failure and 12 (40%) had exertional dyspnea. By echo, mean valve area was 1.72 ± 0.12 cm2 and mean gradient 11.2 ± 1.4 mmHg. Two patients (16.7%) presented moderate aortic regurgitation.ConclusionOur case series demonstrate that even with elevated comorbidity index, clinical endpoints and valve-associated results are relatively favorable in nonagenarians treated with TAVR.

Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile?

“…As deduced from studies reporting results of TAVI in nonagenarians summarized in Table 1, TAVI, as long as it is performed via the transfemoral route, is feasible and relatively safe and effective in this patient subpopulation, albeit at higher risk compared to younger patients, with satisfactory short-and mid-term outcomes, however, long-term data are meagre (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). Procedural and 30-day mortality ranges from 0% to 27%, hovering around 10%, stroke risk ranges from 2% to 18% (average 3-4%), bleeding and vascular complications range from 9% to 34% (average ~16%), renal insufficiency ranges from 1% to 10%, while the emerging need for a pacemaker has a wide range depending on the type of valve employed (5-30%) (41).…”

Transcatheter aortic valve replacement over age 90: Risks vs benefits

“…These structural changes become more severe in response to chronic pressure overload from AS, and they may introduce technical complexity when deploying a transcatheter valve. Nonagenarians undergoing TAVR are also more likely to present with multi‐valve disease; with 15%‐64% exhibiting concomitant moderate or severe mitral regurgitation —a finding associated with a 2‐fold increase in mortality following TAVR . Another common yet concerning finding in nonagenarians is pulmonary hypertension; with 21%‐44% exhibiting systolic pulmonary arterial pressures >60 mmHg …”