Prevalence and Prognostic Significance of Malnutrition in Older Japanese Adults at High Surgical Risk Undergoing Transcatheter Aortic Valve Implantation

Abstract

Background The usefulness of preprocedural nutritional status to stratify prognosis after transcatheter aortic valve implantation has been evaluated; however, the studies conducted so far have been relatively small and/or focused on a single nutritional index. This study sought to assess the prevalence and prognostic impact of malnutrition in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. Methods and Results We applied the Controlling Nutritional Status score, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index to 1040 consecutive older Japanese patients at high surgical risk who underwent transcatheter aortic valve implantation. According to the Controlling Nutritional Status score, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index, 16.6%, 60.5%, and 13.8% patients had moderate or severe malnutrition, respectively; 89.3% were at least mildly malnourished by at least 1 score. Worse nutritional status was associated with older age, lower body mass index, higher degree of frailty, worse symptoms and renal function, atrial fibrillation, and anemia. During a median follow‐up of 986 days (interquartile range, 556–1402 days), 273 (26.3%) patients died. Compared with normal nutrition, malnutrition was associated with an increased risk for all‐cause death (adjusted hazard ratio for moderate and severe malnutrition, respectively: 2.19 (95% CI, 1.45–3.31; P <0.001) and 6.13 (95% CI, 2.75–13.70; P <0.001) for the Controlling Nutritional Status score, 2.02 (95% CI, 1.36–3.02; P =0.001) and 3.24 (95% CI, 1.86–5.65; P <0.001) for the Geriatric Nutritional Risk Index, and 1.60 (95% CI, 1.06–2.39; P =0.024) and 2.32 (95% CI, 1.50–3.60; P <0.001) for the Prognostic Nutritional Index). Conclusions Malnutrition is common in patients undergoing transcatheter aortic valve implantation and is associated with increased mortality.

Transcatheter Aortic Valve Implantation in Elderly Patients With Aortic Valve Stenosis: The Role of Frailty, Malnutrition, and Sarcopenia

“…These are different geriatric syndromes but inextricably intertwined. It did not go unnoticed that Ishizu et al 2 reported a higher prevalence of moderate/severe malnutrition regardless of index used in patients who are frail in comparison with patients who are not frail (statistically significant differences) as measured by the Clinical Frailty Scale. Looking closely at their Table 2 and the intersection between GNRI and Clinical Frailty Scale reported by Ishizu et al, 2 the overlap between frailty and moderate/severe malnutrition is evident.…”

“…It did not go unnoticed that Ishizu et al 2 reported a higher prevalence of moderate/severe malnutrition regardless of index used in patients who are frail in comparison with patients who are not frail (statistically significant differences) as measured by the Clinical Frailty Scale. Looking closely at their Table 2 and the intersection between GNRI and Clinical Frailty Scale reported by Ishizu et al, 2 the overlap between frailty and moderate/severe malnutrition is evident. According to GNRI, 58% of all patients who were moderately/severely malnourished were found to be frail, and 70.6% of all patients who were frail were found to be malnourished.…”

“…An interesting observation in the study by Ishizu 2 was that malnutrition was highly prevalent in patients with a body mass index >22 kg/m 2 using the CONUT and GNRI criteria (65.5% and 61.2%, respectively). We tend to associate malnutrition only with low weight, however, high prevalence of malnutrition in individuals with normal weight or patients who are overweight/obese was also described, which underscores the importance of not excluding the diagnosis of malnutrition simply because an individual is not underweight.…”

“…We should also consider the impact of other possible factors at play in the context of the study by Ishizu et al 2 For instance, the authors described statistically significant differences in the baseline characteristics regarding the presence of left ventricular outflow tract calcification, with higher prevalence in the group with moderate/severe malnutrition regardless of nutritional index applied. It has been demonstrated that the presence of significant left ventricular outflow tract calcification increases the risk of periprocedural and 1‐year mortality, stroke, myocardial infarction, paravalvular leak, and aortic annulus/root rupture after TAVI, 11 and this may have affected their results.…”

“…Malnutrition is one of the hallmarks of frailty in elderly patients and a predictor of worse outcomes in elderly patients with severe aortic valve stenosis. 1 In this context, Ishizu et al 2 present in this issue of the Journal of the American Heart Association ( JAHA) their analyses on prevalence and prognostic value of the Controlling Nutritional Status (CONUT) score, Geriatric Nutritional Risk Index (GNRI), and Prognostic Nutritional Index for malnutrition assessment of Japanese elderly patients at high surgical risk undergoing transcatheter aortic valve implantation (TAVI). They found that malnourishment in their population was common and associated with increased mortality after TAVI regardless of the nutrition index used and irrespective of age, sex, body mass index, frailty, kidney function, and left ventricular ejection fraction.…”