Management of Nonagenarian Patients With Severe Aortic Stenosis: The Role of Comorbidity

Bernal, Eva; Arizá-Solé, Albert; Bayés‐Genís, Antoni; Formiga, Francesç; Díez‐Villanueva, Pablo; Romaguera, Rafael; González-Saldívar, Hugo; Martínez‐Sellés, Manuel

doi:10.1016/j.hlc.2017.02.033

Cited by 19 publications

(14 citation statements)

References 32 publications

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“…Similarly, the majority (~2/3) of nonagenarians with severe aortic stenosis have several comorbidities (30). Among 177 (117 females) nonagenarians with severe aortic stenosis (mean age 91.1 years), only 56 patients (31.6%) had a low (<3) Charlson comorbidity index.…”

Section: Comorbiditiesmentioning

confidence: 99%

“…This holds true for TAVI procedures as well (34). Among comorbidities, cerebrovascular disease, CKD and frailty appear to confer a worse outcome in the very elderly (23,(30)(31)(32). Careful patient selection, a lege artis procedure, a minimalistic approach and vascular hemostasis are of utmost importance for a successful TAVI procedure (35,36).…”

Section: Comorbiditiesmentioning

confidence: 99%

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

Manolis¹,

Manolis²

2017

Ann. Cardiothorac. Surg.

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A growing number of nonagenarians is recorded as life expectancy increases. Unfortunately, this extreme-aged group is plagued by increased prevalence of aortic stenosis amidst a higher occurrence of comorbidities that pose dilemmas to cardiologists and cardiac surgeons when having to choose a conservative or interventional treatment modality, and a surgical or transcatheter aortic valve implantation (TAVI) approach. TAVI is an expensive procedure, which also confers a higher mortality and morbidity risk in nonagenarians, compared to younger patients. Considering the physiologic rather the chronologic age alone, and adopting a shared-decision making approach (participatory medicine), it may be more realistic to determine a patient's candidacy for this non-surgical therapeutic modality. Thus, it comes down to the patient selection process by having the heart team review each nonagenarian case individually and getting the patient and the family involved, always aiming to prolong and improve patient's quality of life (QoL), but also taking into consideration patient preferences and values, sharing and respecting goals, realistic expectations, and end-of-life views and ideas. One should keep in mind that there is always the possibility that TAVI may be clinically futile for patients who have a multitude of comorbidities and extreme frailty, for whom a transition to palliative care might be prudent. Selecting nonagenarian patients with low comorbidity index and with no extreme frailty, adopting a minimalistic approach and paying attention to vascular access hemostasis may provide the elements that may lead to a successful, desirable and hopefully cost-effective outcome.

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Section: Comorbiditiesmentioning

confidence: 99%

Section: Comorbiditiesmentioning

confidence: 99%

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

Manolis¹,

Manolis²

2017

Ann. Cardiothorac. Surg.

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“…Still, most nonagenarians with severe AS will likely have at least one significant comorbidity. In a Spanish study of nonagenarians with severe AS managed both with TAVR and conservatively, the most common comorbidity was chronic kidney disease, which was present in 70% of the cohort . Other comorbidities present in at least 10% of the cohort were diabetes mellitus (32%), myocardial infarction (16%), dementia (13%), and previous stroke (11%).…”

Section: The Nonagenarian Phenotypementioning

confidence: 99%

“…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 …”

Section: The Nonagenarian Phenotypementioning

confidence: 99%

“…In a Spanish study of nonagenarians with severe AS managed both with TAVR and conservatively, the most common comorbidity was chronic kidney disease, which was present in 70% of the cohort. 12 Other comorbidities present in at least 10% of the cohort were diabetes mellitus (32%), myocardial infarction (16%), dementia (13%), and previous stroke (11%). The mean Charlson Comorbidity Index score was 3.2 and only 32% of the cohort had a low comorbidity burden; a high comorbidity burden was associated with increased 1-year mortality.…”

Section: The Nonagenarian Phenotypementioning

confidence: 99%

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Transcatheter aortic valve replacement over age 90: Risks vs benefits

Galatas

Afilalo

2019

Clinical Cardiology

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As the population ages, clinicians will encounter a growing number of nonagenarians suffering from severe aortic stenosis who may be candidates for transcatheter aortic valve replacement (TAVR). By virtue of a healthy survivor effect or a referral bias, these patients may paradoxically have greater resilience and fewer comorbidities than their octogenarian counterparts. They tend to, on average, tolerate the TAVR procedure quite well with low in‐hospital and 1‐year mortality rates of 5.5% and 23%, respectively. Appropriate patient selection should consider individualized estimates of procedural risk, potential for functional recovery and for improved quantity and quality of life. Frailty is much more revealing than chronological age, and it can be measured by brief tools such as the Essential Frailty Toolset. Ultimately, the process of shared decision‐making is paramount to ensure that the course of action is patient‐centered and balances the procedure's expected risks and benefits with the nonagenarian's preferences and values.

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Is Transcatheter Aortic Valve Replacement Futile in Patients Over Ninety Years of Age?

Bernard,

St-Louis,

Robichaud

et al. 2023

CJC Open

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Management of Nonagenarian Patients With Severe Aortic Stenosis: The Role of Comorbidity

Cited by 19 publications

References 32 publications

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

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

Transcatheter aortic valve replacement over age 90: Risks vs benefits

Is Transcatheter Aortic Valve Replacement Futile in Patients Over Ninety Years of Age?

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