ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement

Abstract

Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient’s survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.

CT and MR imaging prior to transcatheter aortic valve implantation: standardisation of scanning protocols, measurements and reporting—a consensus document by the European Society of Cardiovascular Radiology (ESCR)

“…Outside the diagnosis of severe AS, the assessment of comorbidities is of pivotal importance and needs a careful caseby-case analysis. Given the advanced age, frail condition and varying pre-existing conditions of TAVI candidates, a careful multidisciplinary analysis is needed not only to assure procedural eligibility but also to assess the likelihood of postprocedural functional improvement and enhanced quality of life [24]. In this document, we will focus on the contributions of the radiologist.…”

Multidimensional Approach to Frailty

“…Multi-morbidity has a key influence on the diagnostic and therapeutic process, because the manifestation of disease symptoms may differ and make their interpretation difficult. Multi-morbidity is associated with a higher risk of death, higher rate of rehabilitation, disability, and reduced quality of life (Pulignano et al, 2017). Optimization of the clinical status of multi-morbidity patients seems to be important in the context of the perioperative risk in cardiac patients.…”

Frailty and Exercise Training: How to Provide Best Care after Cardiac Surgery or Intervention for Elder Patients with Valvular Heart Disease

“…Most of the studies analyzed frailty before surgery/intervention as prognostic tool for later outcomes [ 9 ] and frailty is a reliable prognostic factor for mortality, morbidity, major complications [ 10 – 16 ], functional decline [ 17 ], quality of life [ 18 ], and risk of delirium after procedure [ 19 , 20 ]. Frailty status can be changed and its assessment should not only be for prognosis but also lead to “pre-rehabilitation” interventions [ 21 ] and clear comprehensive cardiac rehabilitation (CR) recommendations [ 9 , 22 ]. Physical rehabilitation for frail older people can positively affect physical fitness and this effect may be related to level of frailty in a setting of long-term care [ 23 ].…”