Prediction of Poor Outcome After Transcatheter Aortic Valve Replacement

Abstract

BACKGROUND A series of models have been developed to identify patients at high risk for poor outcomes after transcatheter aortic valve replacement (TAVR) to help guide treatment choices, offer patients realistic expectations of long-term outcomes, and support decision making. OBJECTIVES We examined the performance of the previously developed TAVR Poor Outcome risk models in an external dataset and explored the incremental contribution of geriatric domains to model performance. METHODS Poor outcome after TAVR was defined as death, poor quality of life (QOL), or decline in QOL, as assessed using the Kansas City Cardiomyopathy Questionnaire. We tested 4 TAVR Poor Outcome risk models: 6-month and 1-year full and clinical (reduced) models. We examined each model’s discrimination and calibration in the CoreValve trial dataset, then tested the incremental contribution of frailty and disability markers to the model’s discrimination using the incremental discrimination index (IDI). RESULTS Among 2,830 patients who underwent TAVR in the CoreValve US Pivotal Extreme and High Risk trials and associated continued access registries, 31.2% experienced a poor outcome at 6 months following TAVR (death: 17.6%; very poor QOL: 11.6%; QOL decline: 2.0%) and 50.8% experienced a poor outcome at 1 year (death: 30.2%; poor QOL: 19.6%; QOL: decline 1.0%). The models demonstrated similar discrimination as in the Placement of Aortic Transcatheter Valves Trial cohorts (c-indexes: 0.637 to 0.665) and excellent calibration. Adding frailty as a syndrome increased the c-indexes by 0.000 to 0.004 (IDI p < 0.01 for all except the 1-year clinical model), with the most important individual components being disability and unintentional weight loss. CONCLUSIONS Although discrimination of the TAVR Poor Outcome risk models was generally moderate, calibration was excellent among patients with different risk profiles and treated with a different TAVR device. These findings demonstrated the value of these models for individualizing outcome predictions in high-risk patients undergoing TAVR.

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

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Gait Speed Assessment in Transcatheter Aortic Valve Replacement

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The Heart Team, TAVI and natural selection

“…Recent publications are indicating the direction we have to take to select patients appropriately for TAVI. (1) Clearly the decision must be taken by a MDT. The MDT must include sufficient expertise beyond the opinion of the cardiac surgeon and cardiologist involved in the procedure.…”