Relation of Frailty to Outcomes After Transcatheter Aortic Valve Replacement (from the PARTNER Trial)

Green, Philip; Arnold, Suzanne V.; Cohen, David J.; Kirtane, Ajay J.; Kodali, Susheel; Brown, David L.; Rihal, Charanjit S.; Xu, Ke; Lei, Yang; Hawkey, Marian; Kim, Rebeca J.; Alu, Maria; Leon, Martin B.; Mack, Michael J.

doi:10.1016/j.amjcard.2015.03.061

Cited by 208 publications

(185 citation statements)

References 28 publications

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“…On the other hand, octogenarians, in particular, still remain highly vulnerable to complications given their overall age and frailty, independent of the STS-risk score (13,14). Patients with difficulty ambulating, those with poor nutrition and/or concurrent need for another surgery (due to cancer or orthopedic injuries, for example), and frailty would be ideal candidates for TAVR.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of surgical and transcatheter aortic valve replacement in the octogenarians—surgery still the gold standard?

Hirji¹,

Val²,

Kolkailah³

et al. 2017

Ann. Cardiothorac. Surg.

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Background: Contemporary options for aortic valve replacement (AVR) include transcatheter and surgical approaches (TAVR and SAVR). As evidence accrues for TAVR in high and intermediate risk patients, some clinicians advocate that all patients aged over 80 years should only receive TAVR. Our aim was to investigate the utility of SAVR and minimally invasive AVR (mAVR) among octogenarians in the current era of TAVR. Results: Compared to SAVR patients, TAVR patients were relatively older (86.2 versus 84.2 years) with co-morbidities such as chronic kidney disease (CKD), diabetes mellitus (DM), cerebrovascular disease (CVD), and prior myocardial infarction (MI), all P<0.05. The mean STS-PROM for the TAVR group was statistically higher, 6.81 versus 5.58 for the SAVR group (P<0.001). The median in-hospital LOS was statistically higher for the SAVR group (P<0.05). Cox proportional hazard modeling, adjusted for temporal differences in procedure and patient selection, identified age, New York Heart Association (NYHA) class III/IV, preoperative creatinine, severe chronic lung disease, prior cardiac surgery as significant predictors of decreased survival (all P<0.05), while type of intervention (approach) was non-contributory. Adjusted operative mortality stratified by procedure approaches was similar between full sternotomy SAVR and mAVR, and between alternative access and transfemoral TAVR.Conclusions: After adjusting for confounders, TAVR (regardless of approach), SAVR, and mAVR had comparable operative mortality and mid-term survival. Treatment decisions should be individualized with consensus from a multi-disciplinary heart team, taking into account patient co morbidities, frailty, and quality of life. We believe certain patient groups will still benefit from SAVR even in this elderly population.

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Section: Discussionmentioning

confidence: 99%

Outcomes of surgical and transcatheter aortic valve replacement in the octogenarians—surgery still the gold standard?

Hirji¹,

Val²,

Kolkailah³

et al. 2017

Ann. Cardiothorac. Surg.

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“…Our data are more in line with the median gait speed of 0.57 m/s found in a TAVR referral population 17 and 0.38 m/s found in a substudy of the Placement of Aortic Transcatheter Valve (PARTNER) trial. 38 Previously, a gait speed of 0.83 m/s has been proposed as a cutoff with good discrimination properties in a population with heart failure 12 and a population undergoing cardiac surgery. 13 However, >75% of our TAVR population had a gait speed of <0.83 m/s, and one quarter had a gait speed of <0.5 m/s.…”

Section: Discussionmentioning

confidence: 99%

Gait Speed Predicts 30-Day Mortality After Transcatheter Aortic Valve Replacement

et al. 2016

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Gait speed, alone or incorporated into geriatric rating scales, is associated with mortality among community-dwelling individuals, 10 patients with coronary heart disease, 11 elderly patients with heart failure, 12 and those undergoing cardiac surgery, including aortic valve replacement.13 Nevertheless, the association between slow gait speed (which is an indicator of physical frailty) and outcomes after TAVR in US Background-Surgical risk scores do not include frailty assessments (eg, gait speed), which are of particular importance for patients with severe aortic stenosis considering transcatheter aortic valve replacement. Methods and Results-We assessed the association of 5-m gait speed with outcomes in a cohort of 8039 patients who underwent transcatheter aortic valve replacement (November 2011-June 2014) and were included in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. We evaluated the association between continuous and categorical gait speed and 30-day all-cause mortality before and after adjustment for Society of Thoracic Surgeons-predicted risk of mortality score and key variables. Secondary outcomes included in-hospital mortality, bleeding, acute kidney injury, and stroke. The overall median gait speed was 0.63 m/s (25th-75th percentile, 0.47-0.79 m/s), with the slowest walkers (<0.5 m/s) constituting 28%, slow walkers (0.5-0.83 m/s) making up 48%, and normal walkers (>0.83 m/s) constituting 24% of the population. Thirty-day all-cause mortality rates were 8.4%, 6.6%, and 5.4% for the slowest, slow, and normal walkers, respectively (P<0.001). Each 0.2-m/s decrease in gait speed corresponded to an 11% increase in 30-day mortality (adjusted odds ratio, 1.11; 95% confidence interval, 1.01-1.22). The slowest walkers had 35% higher 30-day mortality than normal walkers (adjusted odds ratio, 1.35; 95% confidence interval, 1.01-1.80), significantly longer hospital stays, and a lower probability of being discharged to home. Conclusions-Gait

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“…Frailty status was independently associated with increased mortality [hazard ratio (HR): 1.84; P = 0.028] after TAVI. Other studies have also shown significant associations between frailty indices and 1-year all-cause mortality after TAVI (26,27). An incremental rise in mortality and post-TAVI length of stay with increasing frailty has been reported with dismal prognosis in extremely frail patients (28).…”

Section: Frailtymentioning

confidence: 99%

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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Relation of Frailty to Outcomes After Transcatheter Aortic Valve Replacement (from the PARTNER Trial)

Cited by 208 publications

References 28 publications

Outcomes of surgical and transcatheter aortic valve replacement in the octogenarians—surgery still the gold standard?

Outcomes of surgical and transcatheter aortic valve replacement in the octogenarians—surgery still the gold standard?

Gait Speed Predicts 30-Day Mortality After Transcatheter Aortic Valve Replacement

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

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