Frailty as a risk predictor in cardiac surgery: Beyond the eyeball test

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Impact of Frailty in Patients Undergoing Minimally Invasive Mitral Valve Surgery

OBJECTIVE

Psoas muscle size is a reliable marker of sarcopenia and frailty that correlates with adverse outcomes after cardiac surgery. However, its use in mitral and minimally invasive cardiac surgery is lacking. We sought to determine whether frailty, as measured by psoas muscle index, increases surgical risk for minimally invasive mitral valve surgery.

METHODS

Patients undergoing isolated minimally invasive mitral surgery via right minithoracotomy were identified. Patients who underwent maze, tricuspid intervention, and those who were emergent were excluded. Total psoas muscle area was calculated using the average cross-sectional area at the L3 vertebra on computed tomography scan and indexed to body surface area. Sarcopenia was defined as <25th gender-specific percentile. Patients were stratified by sarcopenia status and outcomes compared.

RESULTS

Of 287 total patients, 192 patients met inclusion criteria. Sarcopenic patients were 6 years older (66 vs 60 years, P = 0.01), had lower preoperative albumin levels (4.0 vs 4.3 g/dL, P < 0.001), and had higher Society of Thoracic Surgeons risk of morbidity/mortality (13.1% vs 9.0%, P = 0.003). Operative major morbidity or mortality was 6.4% versus 5.5% (P = 0.824), while the 1-year mortality rate was 2.1% versus 0% (P = 0.08). After risk adjustment, psoas index did not predict operative morbidity or mortality. However, sarcopenia was associated with higher odds of readmission (odds ratio = 0.74, P = 0.02).

CONCLUSIONS

Contrary to other cardiac operations, for patients undergoing isolated minimally invasive mitral valve surgery, sarcopenia was not associated with increased perioperative risk except for higher readmission rates. Minimally invasive surgical approaches should be strongly considered as the approach of choice in frail patients.

A Geriatric Approach to Percutaneous Coronary Interventions in Older Adults, Part II: A JACC: Advances Expert Panel

We review a comprehensive risk assessment approach for percutaneous coronary interventions in older adults and highlight the relevance of geriatric syndromes within that broader perspective to optimize patient-centered outcomes in interventional cardiology practice. Reflecting the influence of geriatric principles in older adults undergoing percutaneous coronary interventions, we propose a "geriatric" heart team to incorporate the expertise of geriatric specialists in addition to the traditional heart team members, facilitate uptake of the geriatric risk assessment into the preprocedural risk assessment, and address ways to mitigate these geriatric risks. We also address goals of care in older adults, highlighting common priorities that can impact shared decision making among older patients, as well as frequently encountered pharmacotherapeutic considerations in the older adult population. Finally, we clarify gaps in current knowledge and describe crucial areas for future investigation.

Preoperative physical frailty assessment among octogenarians undergoing cardiac surgery: Upgrading the "eyeball" test

OBJECTIVES

There are many well-described, but as yet unproven, physical ability tools to assess frailty. The objective of this study was to evaluate the effectiveness of 4 preoperative physical tests in predicting mortality, morbidity, and functional outcomes among octogenarians undergoing cardiac surgery.

METHODS

Between 2016 and 2019, 200 patients aged 80 years or more undergoing elective cardiac surgery were prospectively recruited. Four physical tests were performed preoperatively: 5-m walk time, timed up-and-go, 5 time sit-to-stand, and handgrip strength tests. The primary end point was a composite of in-hospital mortality, neurologic, and pulmonary complications. Multivariate analysis was performed.

RESULTS

In-hospital mortality was 1.5%. Slow performance on the 5-m walk test (time ≥6.4 seconds) was the only independent predictor of the composite end point among the tests evaluated (odds ratio, 2.70; 95% confidence interval, 1.34-5.45; P = .006). At follow-up, patients with a slow 5-m walk test had a significantly lower midterm survival compared with patients with a normal test result (1-year survival 91.5% vs 98.7%, log-rank P = .03). Mean Physical and Mental Component Scores of the 12-item short form survey were 47.2 ± 8.3 and 53.6 ± 5.9, respectively, which are comparable to those of a general population aged more than 75 years.

CONCLUSIONS

The 5-m walk time test is an independent predictor of a composite of in-hospital mortality and major morbidity, as well as midterm survival. This test could be used as a simple adjunctive preoperative tool for octogenarians undergoing cardiac surgery.

Re-examination of successful agers with lower biological than chronological age still after a 20-year follow-up period

BACKGROUND

Successful ageing is the term often used for depicting exceptional ageing but a uniform definition is lacking. The aim was to re-examine and describe the successful agers living at home at the age of 84 years or over after a 20-year follow-up. The purpose was also to identify possible factors leading to their successful ageing.

METHODS

Successful ageing was defined as the ability to live at home without daily care. Data on the participants' functional ability, objective health, self-rated health and satisfaction with life were gathered at baseline and after a 20-year follow-up period. A measurement of personal biological age (PBA) was established and the difference between the PBA and the chronological age (CA) was counted.

RESULTS

The participants' mean age was 87.6 years (Standard deviation 2.5, range 84-96). All analyzed variables depicted poorer physical ability and subjective health at re-examination than at baseline. Still, 99% of the participants were at least moderately satisfied with their lives. The PBA at baseline was 6.5 years younger than CA, and at re-examination, the difference was even more pronounced at 10.5 years.

DISCUSSION

Even though the participants were chronologically older, had poorer physical ability and subjective health, they were still satisfied with their lives indicating possible psychological resilience. The difference between the PBA and CA was greater at re-examination than at baseline indicating that they were also biologically successful agers.

CONCLUSIONS

Successful agers were satisfied with life despite hardships and had a lower biological than chronological age. Further research is needed to evaluate causality.

Diagnosis and Management of Aortic Valvular Disease in the Elderly

Aortic valvular disease, including aortic stenosis and aortic regurgitation, is increasingly common with age. Due to the aging population, more elderly patients are presenting with aortic valve pathology and expectations for prompt diagnosis and efficacious treatment. The current paradigm for aortic valve disease is based on surgical or interventional therapy. In this review, we discuss the approach to diagnosing aortic valvular disease and the different options for treatment based on the most recent evidence.

Preoperative frailty based on laboratory data and postoperative health outcomes in patients undergoing coronary artery bypass graft surgery

BACKGROUND

Frailty is associated with adverse surgical outcomes. Patients with cardiovascular diseases have many risk factors of frailty; thus, preoperative frailty evaluation is necessary to predict adverse outcomes after coronary artery bypass graft (CABG) surgery. Laboratory data based-frailty assessments are objective and not time-consuming, addressing the need for an accurate but simple frailty screening for patients awaiting CABG surgery.

OBJECTIVES

This retrospective study aimed to determine the association between laboratory based-frailty and patient health outcomes after CABG surgery.

METHODS

We evaluated 896 patients who underwent on-pump or off-pump CABG surgery between August 1, 2015 and July 31, 2020 at a tertiary hospital. The frailty index-laboratory (FI-LAB), which comprises 32 laboratory parameters and vital signs, was used for frailty assessment.

RESULTS

The patients were divided into three groups according to their preoperative FI-LAB level as low (FI-LAB <0.25, 23.0%), moderate (FI-LAB ≥0.25 to ≤0.4, 54.9%), and high (FI-LAB>0.4, 22.1%) frailty groups. In the confounder-adjusted analysis, the lengths of hospital stay and intensive care unit stay were longer by 2.20 days (p=.023) and by 0.89 days (p=.009), respectively, in the high frailty group than those in the low frailty group. The odds ratio for 30-day readmission was also 2.58 times higher in the high frailty group than that in the low frailty group.

CONCLUSION

A high preoperative FI-LAB score indicates increasing risks of adverse postoperative outcomes among CABG surgery patients. FI-LAB has potential strengths to capture the need for a more thorough frailty assessment for cardiac surgery patients.

Prevalence and Prognosis Impact of Frailty Among Older Adults in Cardiac Intensive Care Units

Background

Whether frailty, defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors, may impact the outcomes of elderly patients admitted to a cardiac intensive care unit (CICU) remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted to a CICU.

Methods

This prospective single-centre observational study was conducted among patients aged ≥ 80 years admitted to a CICU in a tertiary centre. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). The population was divided into 3 classes: EFS-score of 0-3, EFS-score of 4-6, and EFS-score > 7.

Results

A total of 199 patients were included, and median follow-up duration was 365 days. The mean age was 84.8 years, and 50 patients (25.1%) died during the follow-up period. In all, 45 (22.6%), 60 (30.2%), and 94 patients (47.2%) had an EFS-score of 0-3, 4-6, and ≥ 7, respectively. The all-cause mortality rate was 4.4%, 27.1%, and 37.2% in the 0-3, 4-6, and ≥ 7 EFS-score groups, respectively (P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: hazard ratio was 2.60 (95% confidence interval 0.54-12.45) within the 4-6 EFS-score group, and 5.46 (95% confidence interval 1.23-24.08) within the ≥ 7 EFS-score group.

Conclusions

Frailty is highly prevalent in older adults admitted to the population hospitalized in a CICU and represents a strong prognostic factor for 1-year all-cause mortality.

Prognostic Value of Handgrip Strength in Older Adults Undergoing Cardiac Surgery

BACKGROUND

Although multidimensional frailty scales have been proven to predict mortality and morbidity in cardiac surgery, there is a need for rapid tools that could be easily administered at the point of care. Handgrip strength (HGS) is an attractive option that can be measured in acutely ill and bed-bound patients, although it has yet to be validated in a large cardiac surgery cohort.

METHODS

This is a post hoc analysis of a multicentre prospective study in older patients undergoing coronary artery bypass grafting and/or valve surgery from 2011 to 2019. HGS was measured before surgery and classified by sex-stratified cutoffs. The primary outcome was 1-year mortality and secondary outcomes were 30-day mortality, discharge disposition, and prolonged length of stay.

RESULTS

There were 1245 patients included in the analysis (mean age 74.0 ± 6.6 years; 30% female). Weak HGS was associated with advanced age, heart failure, kidney disease, malnutrition, and various frailty scales. In those with weak vs normal HGS, respectively, 1-year mortality was 17% vs 6%, 30-day mortality was 10% vs 3%, prolonged length of stay was 34% vs 19%, and discharge to a health care facility was 45% vs 26% (all P < 0.001). After adjustment, HGS was predictive of 1-year and 30-day mortalities, with odds ratios of 2.44 (95% confidence interval [CI] 1.39-4.29) and 2.83 (1.38-5.81), respectively. HGS cutoffs of < 26 kg in men and < 16 kg in women had the highest predictive performance.

CONCLUSIONS

HGS is a simple and effective tool to identify patients at higher risk of mortality and protracted recovery after cardiac surgery.

Factors Associated With Frailty in Patients Undergoing Cardiac Surgery: A Longitudinal Study

BACKGROUND

Frailty may increase the risk of complications and mortality in patients undergoing cardiac surgery. Few studies on frailty and its associated factors have been conducted in these patients.

OBJECTIVE

The aim of this study was to explore frailty and related factors in patients undergoing cardiac surgery.

METHODS

A total of 154 patients undergoing cardiac surgery in northern Taiwan were recruited using a longitudinal study design and interviewed using structured questionnaires assessing physical activity, anxiety and depression, and social support before surgery and at 1 month and 3 months after surgery.

RESULTS

The prevalence of frailty in patients undergoing cardiac surgery was 16.2%, 20.5%, and 16.6% before surgery and at 1 month and 3 months after surgery, respectively. Frail and prefrail patients undergoing cardiac surgery were more likely to be unemployed, have gout, have a higher New York Heart Association class, have preoperative dysrhythmia, undergo cardiopulmonary bypass, have a lower functional ability, have a higher European System for Cardiac Operative Risk Evaluation score, have a longer anesthesia time, have longer endotracheal tube and extracorporeal circulation times, have longer intensive care unit and hospital stays, have lower hemoglobin and albumin levels, have higher anxiety and depression levels, and have lower Mini-Mental State Examination scores. The significant predictors of prefrailty and frailty included unemployment, the presence of gout, higher New York Heart Association classes, less independence in activities of daily living, lower hemoglobin levels, and higher levels of depression.

CONCLUSIONS

Frailty was associated with patients' functional status, perioperative conditions and psychosocial factors. Preoperative assessments of frailty and appropriate interventions are needed to improve frailty in patients undergoing cardiac surgery.

Proper Selection Does Make the Difference: A Propensity-Matched Analysis of Percutaneous and Surgical Cut-Down Transfemoral TAVR

Background. Transcatheter aortic valve replacement (TAVR) is an established technique to treat severe symptomatic aortic stenosis patients with a wide range of surgical risk. Currently, the common femoral artery is the first choice as the main access route for the procedure. The objective of this observational study is to report our experience on percutaneous and surgical cut-down transfemoral TAVRs comparing the two approaches. Methods. From January 2014 to January 2019, five hundred eleven consecutive patients underwent TAVR for severe symptomatic aortic stenosis. We analyzed only elective transfemoral procedures. After propensity score-matching based on age, sex, EuroSCORE II, mean aortic gradient, and left ventricular ejection fraction, we obtained two homogeneous populations: surgical cut-down (n = 119) and percutaneous (n = 225), which were labeled Group 1 and Group 2, respectively. Results. The main findings were that there were no significant procedural outcome differences between the two groups, but Group 2 patients had a shorter length of hospital stay and were more frequently discharged home. At follow-up, Group 1 patients had lower survival rates. Conclusions. An accurate preoperative assessment of the femoral access is mandatory to achieve satisfactory outcomes with transfemoral TAVRs. Nevertheless, the percutaneous approach allows shorter in-hospital stay and the need for rehabilitation, thus potentially decreasing the costs of the procedure.

Predictive Effect of Frailty on Amputation, Mortality, and Ambulation in Patients Undergoing Revascularization for Acute Limb Ischemia

BACKGROUND

Frailty is a common, age-associated syndrome that has been used to predict postoperative outcomes in vascular surgery. This study examines if standard measures of frailty correlate with postoperative outcomes for patients undergoing revascularization for acute limb ischemia (ALI).

METHODS

A retrospective study was conducted on all adult patients undergoing revascularization for ALI at an academic medical center between January 2016 and June 2019. Frailty was calculated with the 11-factor modified frailty index (mFI-11), derived from the Canadian Study of Health and Aging Frailty Index. Outcomes examined included in-hospital mortality, major amputation, site of discharge, and ambulatory status at follow-up.

RESULTS

Fifty-three ambulatory patients presented with ALI during the study time period, with 13.2% deemed not frail (mFI-11 < 3) and 86.8% deemed frail (mFI-11 ≥ 3). Frailty was significantly correlated with discharge to a skilled nursing facility (P = 0.028) and nonambulation at follow-up (P = 0.002). There was no significant correlation with other outcomes, including mortality and amputation. On multivariate analysis, frailty was the only factor contributing to nonambulation at follow-up (P = 0.012). Endovascular treatment did not mitigate the effects of frailty on discharge site and ambulatory status.

CONCLUSIONS

Frailty is exceedingly common in patients with ALI. Although frailty predicts discharge site and nonambulation at follow-up, it is not associated with amputation or death. Therefore, frail patients should not be denied open or endovascular revascularization for ALI.

Association between frailty and self-reported health following heart valve surgery

Background

Knowledge about the association between frailty and self-reported health among patients undergoing heart valve surgery remains sparse. Thus, the objectives were to I) describe changes in self-reported health at different time points according to frailty status, and to II) investigate the association between frailty status at discharge and poor self-reported health four weeks after discharge among patients undergoing heart valve surgery.

Methods

In a prospective cohort study, consecutive patients undergoing heart valve surgery, including transapical/transaortic valve procedures were included. Frailty was measured using the Fried score, and self-reported health using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQoL-5 Dimensions 5-Levels Health Status Questionnaire (EQ-5D-5L).To investigate the association between frailty and self-reported health, multivariable logistic regression models were used. Analyses were adjusted for sex, age, surgical risk evaluation (EuroScore) and procedure and presented as odds ratios (OR) with 95% confidence intervals (CI).

Results

Frailty was assessed at discharge in 288 patients (median age 71, 69% men); 51 patients (18%) were frail. In the multivariable analyses, frailty at discharge remained significantly associated with poor self-reported health at four weeks, OR (95% CI): EQ-5D-5L Index 3.38 (1.51-7.52), VAS 2.41 (1.13-5.14), and KCCQ 2.84 (1.35-5.97).

Conclusion

Frailty is present at discharge in 18% of patients undergoing heart valve surgery, and being frail is associated with poor self-reported health at four weeks of follow-up. This supports a clinical need to address the unique risk of frail patients among heart valve teams broadly, and not only to measure frailty as a marker of operative risk.

Can you see frailty? An exploratory study of the use of a patient photograph in the transcatheter aortic valve implantation programme

BACKGROUND

Frailty is an important consideration in the assessment of transcatheter aortic valve implantation patients. The documentation of a patient photograph to augment the objective measurement of frailty has been adopted by some transcatheter aortic valve implantation multidisciplinary (TAVI) programmes.

METHODS

We used a prospective two-part multimethod study design. In part A, we examined the concordance between the Essential Frailty Toolset (EFT) and the score attributed by healthcare professionals based on visual rating of photographs using kappa estimates and linear regression. In part B, we conducted a content analysis qualitative study to elicit information about how the TAVI multidisciplinary team used photographs to form impressions about frailty.

FINDINGS

Part A: 94 healthcare professionals (registered nurses/allied health 65%; physicians 35%) rated 40 representative photographs (women 42.5%; mean age 83.4±7.5; mobility aid 40%) between 0 (robust) and 5 (very frail). The estimate of weighted kappa was 0.2575 (95% confidence interval 0.082-0.433), indicating fair agreement between median healthcare professional visual and EFT score, especially when the EFT was 1 or 4. There was significant discordance among raters (kappa estimate 0.110, 95% confidence interval 0.079-0.141). Age, sex and mobility aid did not have a significant effect on score discordance. Part B: 12 members of the TAVI multidisciplinary team (registered nurses 27.5%; physicians 72.5%) were shown a series of six representative patient photographs. The following themes emerged from the data: (a) looking at the outside; (b) thinking about the inside; (c) use but with caution; and (d) a better approach.

CONCLUSION

A patient photograph offers complementary information to the multimodality assessment of TAVI patients.