Assessing the Risk of Aortic Valve Replacement for Severe Aortic Stenosis in the Transcatheter Valve Era

Abstract

Surgical aortic valve replacement had been the only definitive treatment of severe aortic stenosis before the availability of transcatheter valve technology. Historically, many patients with severe aortic stenosis had not been offered surgery, largely related to professional and patient perception regarding the risks of operation relative to anticipated benefits. Such patients have been labeled as "high risk" or "inoperable" with respect to their suitability for surgery. The availability of transcatheter aortic valve replacement affords a new treatment option for patients previously not felt to be optimal candidates for surgical valve replacement and allows for the opportunity to reexamine the methods for assessing operative risk in the context of more than 1 available treatment. Standardized risk assessment can be challenging because of both the imprecision of current risk scoring methods and the variability in ascertaining risk related to operator experience as well as local factors and practice patterns at treating facilities. Operative risk in actuality is not an absolute but represents a spectrum from very low to extreme, and the conventional labels of high risk and inoperable are incomplete with respect to their utility in clinical decision making. Moving forward, the emphasis should be on developing an individual assessment that takes into account procedure risk as well as long-term outcomes evaluated in a multidisciplinary fashion, and incorporating patient preferences and goals in a model of shared decision making.

Assisted care as a baseline patient risk characteristic affecting the outcome of transcatheter aortic valve insertion

“…The risk calculator uses well defined covariates to estimate operative risk. With the advent of transcatheter valve insertion, the precision of the STS predicted risk of mortality has come under examination as other non‐database covariates are being recognized to affect operative risk . One example of such a non‐database covariate is frailty.…”

The impact of frailty on mortality after transcatheter aortic valve replacement

“…Studies have demonstrated associations of frailty with dysregulation of the immune, hormonal, and endocrine systems including up-regulation of inflammatory cytokines, decreased testosterone levels, and glucose intolerance due to insulin resistance, leading to physical inactivity, malnutrition, and sarcopenia (a state of progressive decline in muscle mass and strength) (16,19). The presence of frailty has been associated with many adverse outcomes including an increased risk of falls, disability, institutionalization, health care resource use as well as mortality (8,(20)(21)(22)(23).…”

“…This syndrome is very prevalent is reported in up to 80% of patients undergoing TAVR (5)(6)(7). Previous studies have demonstrated the adverse effects of frailty on outcomes including disability, dependency, falls, the need for long-term care facility and mortality after cardiac surgery and procedures, such as coronary artery bypass grafting, valve repair or replacement, TAVR, or combined procedures (4,(8)(9)(10)(11).…”

Tratamiento de la estenosis valvular aórtica severa degenerativa: actualidad y futuro. Perspectiva del cirujano cardíaco

“…Estudios realizados en subpoblaciones mayores de 80 años con EA severa sintomática han demostrado que la sustitución valvular reduce la mortalidad al año y a los 5 años a 13% y 32% respectivamente 7 . Sin embargo solo entre el 50% y el 70% de los pacientes se llegan a operar, debido a que una parte importante de esta población es de edad avanzada y tiene múltiples comorbilidades, que hacen que se desestimen para cirugía convencional por su elevado riesgo quirúrgico [8][9][10] . El diagnóstico de la EA es sencillo con una adecuada anamnesis y exploración física sistmática.…”