Should Transcatheter Aortic Valve Replacement Be Performed in Nonagenarians?: Insights From the STS/ACC TVT Registry

Comparison of Lipoprotein(a)-Levels in Patients ≥70 Years of Age With Versus Without Aortic Valve Stenosis

Although lipoprotein(a) (Lp[a]) is linked with aortic valve calcification and clinical aortic valve stenosis (AVS) in middle-aged cohorts, patients aged ≥70 years represent a majority of patients with AVS, in which mechanisms leading to AVS may differ. We sought to determine whether Lp(a) distinguishes patients ≥70 years with and without AVS. We matched 484 patients ≥70 years with AVS, scheduled for transcatheter aortic valve implantation with 484 patients without AVS by age group and gender. Lp(a) levels were compared in patients with and without AVS and stratified by presence and absence of clinical coronary artery disease (CAD) manifestation. A total of 968 patients (mean age 80 ± 5 years, 48% women) were included. When comparing patients with and without AVS, no difference in Lp(a) was observed (AVS: 17 [8; 56] mg/dl, no AVS: 18.5 [8.5; 57] mg/dl, p = 0.56). In contrast, patients with clinical CAD manifestation had higher Lp(a) levels than those without clinical CAD manifestation (coronary artery disease: 19 [9; 60] mg/dl, no coronary artery disease 15 [7; 44] mg/dl, p = 0.0006). In regression analysis, no significant association of Lp(a) with AVS was observed in unadjusted (OR [95% CI]: 0.98 [0.91 to 1.06], p = 0.59) and risk factor-adjusted models (0.98 [0.90 to 1.06], p = 0.57). However, Lp(a) was independently associated with clinical CAD manifestation (unadjusted: 1.14 [1.04 to 1.24], p = 0.003, risk factor adjusted: 1.17 [1.07 to 1.27], p = 0.0006). In conclusion, in a large cohort of patients ≥70 years, Lp(a) was associated with clinical CAD manifesation, but not with AVS. Our results suggest that in patients over 70 years, the development of AVS is not influenced by Lp(a).

Updates on transcatheter aortic valve replacement: Techniques, complications, outcome, and prognosis

Transcatheter aortic valve replacement (TAVR) initially emerged as a therapeutic option for high-risk patients with severe aortic stenosis. Advancement in technologies since the first era of TAVRs, experience from previous obstacles, and lessons learned from complications have allowed the evolution of this procedure to the current state. This review focuses on the updates on the most current devices, complications, and outcomes of TAVR.

Comparison of Outcomes of Transfemoral Aortic Valve Implantation in Patients <90 With Those >90 Years of Age

In patients who underwent transcatheter aortic valve implantation (TAVI), postoperative mortality risk is commonly assessed with risk scores such as the Society of Thoracic Surgeons-Postoperative Risk of Mortality (STS-PROM) and EuroSCORE II, in which age plays a dominant role. However, we reason that in the naturally selected oldest-old patients (nonagenarians), this may not be completely justified and that therefore age should play a minor role in decision-making. The objective of this study was to compare procedural outcome and mid-term mortality of transfemoral (TF)-TAVI patients aged ≥90 years with patients aged <90 years. In this single-center analysis of 599 prospectively acquired consecutive TF-TAVI patients between 2009 and 2017, we compared patients aged ≥90 (i.e., nonagenarians, n = 47) with patients aged <90 years (n = 552), using Kaplan-Meyer analysis and multivariate logistic regression. In the nonagenarians, we found more aortic regurgitation, moderate to severe paravalvular leakage, strokes and vascular complications, and less device success and bleeding complications compared with patients <90 years. Both groups showed similar symptomatic improvement. The predicted (STS-PROM) and actual procedural mortality were 8.033% and 2.1% (3.8×) and 4.868% and 1.8% (2.7×) for the nonagenarians and controls, respectively. Survival was not statistically different at the 1-, 2-, 3-, 4-, and 5-year mark. In conclusion, nonagenarians had similar symptomatic improvement and acceptable procedural outcome and mid-term survival to TF-TAVI patients aged <90 years. Thus, age is not a risk factor in predicting postoperative outcome and mortality and therefore should not be a reason to deny the oldest-old patient transfemoral TAVI.

Early mortality and safety after transcatheter aortic valve replacement using the SAPIEN 3 in nonagenarians

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has been performed for many elderly patients with severe aortic stenosis (AS). The SAPIEN 3 is one of the latest balloon-expandable prosthesis. This study aimed to investigate the early clinical outcomes after TAVR using the SAPIEN 3 in nonagenarians.

METHODS

A total of 97 consecutive patients underwent TAVR for severe AS between December 2015 and December 2016. Of these, 85 consecutive patients who underwent TAVR using the SAPIEN 3 were included. According to the age, patients were classified into age ≥ 90 years group (17 patients) or age < 90 years group (68 patients). The clinical outcomes including all-cause mortality and composite endpoint of early safety at 30 days were evaluated.

RESULTS

The Society of Thoracic Surgeons score in age ≥ 90 years group was higher than age < 90 years group (12.3 ± 6.1% vs. 8.5 ± 5.1%, P < 0.01). There was no significant difference in 30-day mortality between the two groups. However, the life-threatening bleeding and major vascular complications in age ≥ 90 years group were greater than age < 90 years group (11.8% vs. 1.5%, P = 0.04 and 11.8% vs. 1.5%, P = 0.04, respectively). The composite endpoint of early safety at 30 days was similar between the two groups. Multivariate logistic regression analysis showed that prior myocardial infarction was an independent predictor of the composite endpoint of early safety (odds ratio: 4.76, 95% confidence interval: 1.02-22.21, P = 0.047).

CONCLUSIONS

The early mortality and safety after TAVR using the SAPIEN 3 in nonagenarians were similar and acceptable despite of higher operative risk.

Understanding experiences of undergoing transcatheter aortic valve implantation: one-year follow-up

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is the treatment of choice for frail, older adults with severe symptomatic aortic stenosis. Although research about long-term clinical outcomes is emerging, there is limited evidence from the perspectives of patients and family caregivers on their perceived benefits and challenges after TAVI.

AIMS

The aim of this study was to describe older adults and family caregivers' perspectives on undergoing TAVI at one year post-procedure.

METHODS

Qualitative description was the method of inquiry. A purposive sample of 31 patients and 15 family caregivers was recruited from a TAVI programme in western Canada. Semi-structured interviews were conducted with participants one year after TAVI. Data were analysed thematically.

RESULTS

All participants were satisfied with the decision to undergo TAVI. There were three central themes. First, recovery was experienced in the context of aging and comorbidities, which was shaped by patients' limited options for care and post-procedure symptom burden. Second, reconciling expectations with reality meant that, for some patients, symptom burden remained prevalent and was also influenced by others' expectations. Third, recommendations for recovery related to having information needs met, keeping informed of evolving care processes, and addressing individualised needs for support.

CONCLUSIONS

The perspectives of participants provide a valuable contribution to the literature about undergoing TAVI. Clinicians need to be attentive to patients' expectations of benefit and temper these with consideration of the individual's broader health situation to provide treatment decision support. Patients and family caregivers also need adequate teaching and support to facilitate safe transition home given the shift towards early discharge after TAVI.

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

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.

Relative Survival After Transcatheter Aortic Valve Implantation: How Do Patients Undergoing Transcatheter Aortic Valve Implantation Fare Relative to the General Population?

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is indicated for patients with aortic stenosis who are intermediate-high surgical risk. Although all-cause mortality rates after TAVI are established, survival attributable to the procedure is unclear because of competing causes of mortality. The aim was to report relative survival (RS) after TAVI, which accounts for background mortality risks in a matched general population.

METHODS AND RESULTS

National cohort data (n=6420) from the 2007 to 2014 UK TAVI registry were matched by age, sex, and year to mortality rates for England and Wales (population, 57.9 million). The Ederer II method related observed patient survival to that expected from the matched general population. We modelled RS using a flexible parametric approach that modelled the log cumulative hazard using restricted cubic splines. RS of the TAVI cohort was 95.4%, 90.2%, and 83.8% at 30 days, 1 year, and 3 years, respectively. By 1-year follow-up, mortality hazards in the >85 years age group were not significantly different from those of the matched general population; by 3 years, survival rates were comparable. The flexible parametric RS model indicated that increasing age was associated with significantly lower excess hazards after the procedure; for example, by 2 years, a 5-year increase in age was associated with 20% lower excess mortality over the general population.

CONCLUSIONS

RS after TAVI was high, and survival rates in those aged >85 years approximated those of a matched general population within 3 years. High rates of RS indicate that patients selected for TAVI tolerate the risks of the procedure well.

Quality and Safety in Health Care, Part XXXI: Selected Risk Factors for Transcatheter Aortic Valve Replacement

The Transcatheter Valve Therapy Registry has been very helpful in providing data to better understand patient risk factors for transcatheter aortic valve replacement (TAVR). The outcome of TAVR depends on many patient indicators, some of which are given in this article, including the age, dependence on oxygen, classification of pulmonary disease, gender, and the speed of walking. Patient characteristics also help determine which approach will be used to place the device. There are models for the outcome of the TAVR procedure now and more being developed.

Never Too Late: A Case Report on Transcatheter Aortic Valve Implantation in a 97-Year-Old Patient

Aortic valve stenosis is a well-recognized valvular problem in the aging population. Transcatheter aortic valve implantation (TAVI) is becoming an increasingly popular treatment alternative to surgical aortic valve replacement for frail elderly individuals with symptomatic severe aortic valve stenosis. There are multiple research reports documenting the effectiveness of TAVI in octogenarians; however, few authors discuss the success of this procedure in nonagenarians. This case report depicts the successful transfemoral implantation of a prosthetic aortic valve in a 97-year-old man. Moreover, the current literature on TAVI outcomes in nonagenarians is reviewed.

Transcatheter Aortic Valve Implantation in Nonagenarians: Procedural Outcome and Mid-Term Results

BACKGROUND

For nonagenarians with symptomatic severe aortic stenosis transcatheter aortic valve implantation (TAVI) has become a feasible therapeutic option. Therefore, the aim of this study was to evaluate the procedural outcomes and mid-term follow-up in this patient group and compare this to octogenarians.

METHODS

From 1359 patients who underwent TAVI at our institution between March 2009 and February 2016, 82 patients were nonagenarians and 912 were octogenarians. In nonagenarians, mean age was 91.9±1.4years and compared to octogenarians showed a significantly higher logistic EuroScore (27.7±14.8% vs. 23.1±14.4, p=0.005) and STS Score (8.5±4.8% vs. 6.3±6.7, p=0.001).

RESULTS

There were no significant differences with regard to stroke rate, pacemaker implantation rate and major vascular complications between the two groups. Thirty-day mortality was 9.8% in nonagenarians and 4.1% in octogenarians (p=0.04). At 1 year, all-cause mortality increased to 30.9% vs. 18.6% (n.s.).

CONCLUSION

Nonagenarians showed an increased periprocedural mortality during TAVI and higher mortality in follow-up compared to octogenarians. Age alone is not a predictive factor but indication for treatment should be carefully evaluated by the heart team on an individual basis.

ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement

Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient's survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.

Comparison of late mortality after transcatheter aortic valve implantation versus surgical aortic valve replacement: Insights from a meta-analysis

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) has shown non-inferior late mortality in severe aortic stenosis (AS) patients in intermediate to inoperable risk for surgery compared to surgical aortic valve replacement (SAVR). Late outcome of TAVI compared to SAVR is crucial as the number of TAVI continues to increase over the last few years.

METHODS

A comprehensive literature search of PUBMED and EMBASE were conducted. Inclusion criteria were that [1] study design was a randomized controlled trial (RCT) or a propensity-score matched (PSM) study: [2] outcomes included >2-year all-cause mortality in both TAVI and SAVR. The random-effects model was utilized to calculate an overall effect size of TAVI compared to SAVR in all-cause mortality. Publication bias was assessed quantitatively with Egger's test.

RESULTS

A total of 14 studies with 6503 (3292 TAVI and 3211 SAVR, respectively) were included in the meta-analysis. There was no difference in late all-cause mortality between TAVI and SAVR (HR 1.17, 95%CI 0.98-1.41, p=0.08, I²=61%). The sub-group analysis of all-cause mortality of RCT (HR 0.93 95%CI 0.78-1.10, p=0.38, I²=40%) and PSM studies (HR 1.44 95%CI 1.15-1.80, p=0.02, I²=35%) differed significantly (p for subgroup differences=0.002). Meta-regression implicated that increased age and co-existing CAD may be associated with more advantageous effects of TAVI relative to SAVR on reducing late mortality. There was no evidence of significant publication bias (p=0.19 for Egger's test).

CONCLUSIONS

TAVI conferred similar late all-cause mortality compared to SAVR in a meta-analysis of RCT but had worse outcomes in a meta-analysis of PSM.

Transcatheter Aortic Valve Replacement Outcomes in Nonagenarians Stratified by Transfemoral and Transapical Approach

BACKGROUND

Survival and other outcomes of nonagenarians undergoing transcatheter aortic valve replacement (TAVR) in the Medicare population are unclear.

METHODS

Patients aged 65 years and older who underwent TAVR from November 2011 through 2013 were considered for inclusion.

RESULTS

The study consisted of 18,283 patients and 19.3% were aged 90 years or older. Compared with patients younger than 90 years, patients 90 years or older were less likely to have a number of comorbidities, including previous myocardial infarction (17.5% versus 21.8%), previous coronary artery bypass grafting (20.0% versus 35.0%), and chronic obstructive pulmonary disease (25.4% versus 39.0%) among others. The 30-day and 1-year mortality rates were 8.4% versus 5.9% (p = 0.0001) and 25.4% versus 21.5% (p = 0.0001) in the older and younger groups, respectively (odds ratio [OR] 1.47, 95% confidence interval [CI]: 1.28 to 1.70, p = 0.0001). Patients 90 years and older were more likely to undergo pacemaker insertion (11.1% versus 8.3%, p = 0.0001). Among nonagenarians, compared with the transapical group, patients undergoing transfemoral TAVR had lower 30-day (7.2% versus 13.6%, p = 0.0001) and 1-year (23.8% versus 31.6%, p = 0.0001) mortality rates, were more likely to be discharged home (54.4% versus 34.1%, p = 0.0001), and had lower 30-day readmission rates (23.8% versus 31.8%, p = 0.0001). After adjustment for patient characteristics, transapical TAVR was an independent predictor of 30-day mortality rate (OR 1.94, 95% CI: 1.48 to 2.56, p = 0.0001) and readmission (OR 1.46, 95% CI: 1.19 to 1.80, p = 0.0003).

CONCLUSIONS

In patients undergoing TAVR, although 30-day and 1-year mortality rates were slightly worse for nonagenarians than their younger counterparts, long-term survival was still encouraging, with 75% of nonagenarians living to 1 year. Transapical TAVR was associated with worse outcomes in nonagenarians.

Comparative Outcomes of Surgical and Transcatheter Aortic Valve Replacement for Aortic Stenosis in Nonagenarians

Transcatheter aortic valve replacement (TAVR) emerged as a promising alternative to surgical aortic valve replacement (SAVR) in extreme-aged patients with severe aortic stenosis (AS). Data on the outcomes of TAVR or SAVR in nonagenarians are limited. The Nationwide Inpatient Sample was used to identify patients aged 90 years or older who underwent TAVR or SAVR from 2004 to 2013. In-hospital morbidity and mortality were assessed. From 2004 to 2013, 9,066 (national estimate) nonagenarians underwent aortic valve replacement. After the introduction of TAVR, most nonagenarians were treated with TAVR (76%) compared with SAVR (24%). A total of 1,847 nonagenarians who underwent SAVR (n = 1,152) or TAVR (n = 695) were included in the analysis. In-hospital mortality was similar between patients who underwent SAVR (6.4%) compared with TAVR (6.5%; p = 0.29). Vascular complications were more common after TAVR (11.9% vs 6.3%, p <0.001), whereas blood transfusion (46.2% vs 33.7%, p <0.001), and acute kidney injury (25.8% vs 20.4%, p = 0.009) were more common after SAVR. Pacemaker implantation and stroke rates were similar between the 2 groups. In a propensity-matched analysis of 630 patients who underwent isolated TAVR (n = 315) or SAVR (n = 315), in-hospital mortality was similar for (6.0% for SAVR vs 7.9% for TAVR, p = 0.35). SAVR was associated with higher rates of acute kidney injury (24.1% vs 16.8%, p = 0.02) and blood transfusion (46.0% vs 35.2%, p = 0.001), whereas TAVR was associated with increased rates of vascular complications (10.2% vs 6.0%, p = 0.07). Stroke (4.1% vs 4.1%, p = 0.99) and pacemaker implantation rates were also similar (13.0% vs 9.2%, p = 0.12) between the TAVR and SAVR groups, respectively. In conclusion, in nonagenarians, both SAVR and TAVR can be performed with acceptable in-hospital outcomes. Referral for aortic valve replacement in these patients should not be precluded based on age alone.

Changing concept in treatment of asymptomatic severe aortic stenosis and normal ejection fraction: time for biomarkers reappraisal

The uncertainty of whether/how to treat asymptomatic patients with isolated severe aortic stenosis and normal left ventricular ejection fraction is one of the most topical in cardiovascular medicine. Recently, the AVATAR trial: first ever randomized trial in the setting of aortic stenosis has been started in an attempt to adequately address this 'burning issue'. In light of this fact it is important to identify biomarkers which might help in risk stratification of these patients, not only in the referring physician's office during a routine exam, but also for preoperative patients scheduled for surgical replacement/transcatheter aortic valve implantation. This report is focusing on novel laboratory parameters which might be helpful in this risk stratification.

Clinical outcome in nonagenarians undergoing transcatheter valve replacement

Background

Nonagenarians are mostly denied from different therapeutic strategies due to high preoperative risk. We present the results of nonagenarians with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).

Methods

Our retrospective analysis include baseline and procedural data along with clinical outcome. Clinical follow-up was performed in all patients after TAVR.

Results

Out of 689 patients, 33 nonagenarians with a mean age of 90.9 ± 1.4 years suffering from severe AS and elevated comorbidity index (logistic EuroSCORE of 16.3 ± 9.6%, STS score 11.1 ± 9.9%) underwent TAVR between September 2009 and July 2016 using self-expanding prosthesis. Baseline transthoracic echocardiography reported a mean aortic valve area (AVA) of 0.64 ± 0.12 cm2 with a mean pressure gradient of 56.1 ± 16.1 mmHg. Five (16.2%) patients had postprocedural moderate/severe aortic regurgitation. One patient died intraoperally due to ventricular perforation during predilatation, while two patients died within the first 30 days, one due to cardiogenic shock and the other due to pneumonia. No patient experienced a myocardial infarction or a stroke, while ten (30.3%) required permanent pacemaker placement. At follow-up (mean 20.3 months, range 1–78 months), all cause and cardiovascular mortality was 24.2% and 15.1%, respectively. Two patients presented heart failure and 12 (40%) had exertional dyspnea. By echo, mean valve area was 1.72 ± 0.12 cm2 and mean gradient 11.2 ± 1.4 mmHg. Two patients (16.7%) presented moderate aortic regurgitation.

Conclusion

Our case series demonstrate that even with elevated comorbidity index, clinical endpoints and valve-associated results are relatively favorable in nonagenarians treated with TAVR.

Transcatheter aortic valve replacement: The year in review 2016

Transcatheter aortic valve replacement (TAVR) continued to make major strides in 2016, simultaneously expanding its application to lower risk patients as well as more technically challenging subsets of patients with aortic stenosis (AS). The two major accomplishments this year were the establishment of TAVR as the preferred treatment strategy over surgical aortic valve replacement (SAVR) in intermediate risk patients, and initial signals that TAVR and SAVR may be clinically equivalent in low-risk populations. Meanwhile, there is continued expansion of TAVR to challenging clinical subsets (bicuspid aortic valve [BAV], patients with concomitant advanced coronary artery disease [CAD], and failed surgical bioprostheses), and encouraging initial experiences with newer transcatheter heart valve systems. This paper summarizes the major research studies published on TAVR in 2016.

Prognostic value of body mass index and body surface area on clinical outcomes after transcatheter aortic valve implantation

BACKGROUND

Inverse associations between Body Mass Index (BMI) and Body Surface Area (BSA) with mortality in patients after Transcatheter Aortic Valve Implantation (TAVI) have been reported. This "obesity paradox" is controversial, and it remains unclear which parameter, BMI or BSA, is of greater prognostic value. The aim of this study was to investigate the association of BMI and BSA on short- and mid-term outcomes after TAVI.

METHODS AND RESULTS

This prospective, observational study consisted of 917 consecutive patients undergoing TAVI at our center from 2011 to 2014. The association between BMI/BSA and mortality (at 30 days and 1 year) was assessed using restricted cubic spline functions in propensity-adjusted (by Society of Thoracic Surgeons (STS) risk factors) logistic and Cox proportional models, respectively. The median age of the patients was 82.6 years, with a mean STS Predicted Risk of Mortality (STS-PROM) of 6.6 ± 4.3 %. Throughout the study period (mean follow-up time was 297 days), 150 (16.4 %) patients died; 72 (7.9 %) patients died within 30 days of TAVI. After risk adjustment, the association between body constitution and 30-day mortality was not significant for either measure (BMI p = 0.25; BSA p = 0.32). However, BMI (p = 0.01), but not BSA (p = 0.13), was significantly associated with 1-year survival. There was no association between stroke, vascular complications, or length of stay with BMI or BSA.

CONCLUSIONS

BMI was associated with survival at 1-year after TAVI. Despite the trend towards implementing BSA in risk score calculation, BMI may be more suitable for the assessment of TAVI patients.