Clinical Outcomes of Transcatheter Aortic Valve Replacement in Nonagenarians: A Systematic Review and Meta-Analysis

Acute limb ischemia in nonagenarians: Characteristics and factors related to outcomes in a single-center consecutive series

BACKGROUND

The increasing aging and frailty of the population make the management of acute limb ischemia (ALI) more difficult, with decision-making far from being guided by evidence. The aim of the study was to evaluate the characteristics and results of ALI treatment in nonagenarians.

MATERIALS AND METHODS

Retrospective analysis of a consecutive series of nonagenarian patients with ALI attended at our institution between 2008 and 2021. The primary outcomes of the study were 1-year limb salvage and survival rates.

RESULTS

A total of 102 patients were included (mean age 92.38, 78.4% women). In 83 cases (81.4%) ALI was attributed to embolism, and 19 (18.6%) to acute arterial thrombosis. One-month overall survival was 70.6%. Fifteen patients (14.7%) were treated palliatively, including 8 (53.3%) irreversible ALI with associated malignancy/advanced dementia, 5 (33.3%) with associated cerebral/intestinal ischemia and 2 (13.3%) with aortic occlusion and poor medical condition. None of these patients survived after 10 days. The remaining 87 patients (85.3%) were treated with isolated anticoagulation (n = 8, 9.1%), primary major amputation (n = 1, 1.1%) or revascularization (n = 78, 89.6%), including 69 (67.6%) embolectomies, 6 (5.9%) bypass and 3 (2.9%) endovascular techniques. One-year limb salvage and survival rates were 96% and 48%, respectively. Predictive factors of lower survival included anemia (HR = 1.81, p = 0.014) and ALI severity (HR = 1.73, p = 0.032), but not cognitive or functional status. Patients surviving the ALI episode had a 1-year survival rate significantly below that of a similar matched population.

CONCLUSION

Although nonagenarians with an ALI are often functionally and cognitively impaired and have a limited life expectancy, most patients need revascularization for limb salvage and this can be done successfully with a low invasive surgery.

Is Transcatheter Aortic Valve Replacement Futile in Patients Over Ninety Years of Age?

Background

Clinical outcomes and quality of life (QoL) indices are not well described after transcatheter aortic valve replacement (TAVR) in patients aged ≥ 90 years.

Methods

We conducted a retrospective cohort study of TAVR among nonagenarian patients between 2008 and 2020. The survival of TAVR patients among nonagenarians was compared to the provincial estimated survival for an age- and sex-matched general population. QoL was assessed up to 1 year postintervention, using standardized questionnaires.

Results

During the study period, n = 268 patients aged ≥ 90 years were evaluated for severe aortic stenosis. TAVR was performed in n = 171 (48% female; median [IQR] Rockwood Clinical Frailty Scale score: 4 [3-4]); n = 84 underwent medical therapy; and n = 13 underwent surgical aortic valve replacement. Survival was significantly better following TAVR, compared to that after MT (adjusted hazard ratio [95% CI]: 1.99 [1.37-2.88], P < 0.001). TAVR patients demonstrated a survival advantage compared with the general population, with an estimated relative mortality of 0.86 (0.75-0.87). TAVR patients showed sustained improvements in functional status and QoL up to 1 year compared to baseline (all P < 0.05): the 6-minute walk test results improved from 192 to 252 m; the Kansas City Cardiomyopathy Questionnaire score improved from 64 to 81; the Duke Activity Status Index score improved from 13 to 16; and the health state scale result of the Euro Quality of life - 5 Dimensions improved from 63% to 74%.

Conclusions

Nonagenarians undergoing TAVR experience a slightly better survival rate, compared to that of an age- and sex-matched general population, and they have significant improvements in functional status and several QoL indices following the procedure.

Age-Related Outcomes After Transcatheter Aortic Valve Replacement: Insights From the SwissTAVI Registry

OBJECTIVES

The aim of this study was to investigate age-related outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) as assessed in a nationwide, prospective, multicenter cohort study.

BACKGROUND

TAVR is the preferred treatment for elderly patients with severe aortic stenosis and is expanding into lower age groups.

METHODS

Data from the SwissTAVI Registry were analyzed. Clinical outcomes were compared between patients 70 years of age or younger (n = 324), 70 to 79 years of age (n = 1,913), 80 to 89 years of age (n = 4,353), and older than 90 years of age (n = 507). Observed deaths were correlated with expected deaths in the general Swiss population using standardized mortality ratios.

RESULTS

Between February 2011 and June 2018, 7,097 patients (mean age 82.0 ± 6.4 years, 49.6% women) underwent TAVR at 15 hospitals in Switzerland. Procedural characteristics were similar; however, older patients more often had discharge to the referring hospital or a rehabilitation facility after TAVR. Using adjusted analyses, a linear trend for mortality (30-day adjusted hazard ratio [HR_adj]: 1.45; 95% confidence interval [CI]: 1.18 to 1.77; 1-year HR_adj: 1.12; 95% CI: 1.01 to 1.24), cerebrovascular accidents (30-day HR_adj: 1.35; 95% CI: 1.09 to 1.66; 1-year HR_adj: 1.21; 95% CI: 1.02 to 1.45), and pacemaker implantation (30-day HR_adj: 1.23; 95% CI: 1.12 to 1.34; 1-year HR_adj: 1.19; 95% CI: 1.09 to 1.30) was observed with increasing age. Furthermore, standardized mortality ratios were 12.63 (95% CI: 9.06 to 17.58), 4.09 (95% CI: 3.56 to 4.74), 1.63 (95% CI: 1.50 to 1.78), and 0.93 (95% CI: 0.76 to 1.14) for TAVR patients in relation to the Swiss population <70, 70 to 79, 80 to 89 and ≥90 years of age, respectively.

CONCLUSIONS

Increasing age is associated with a linear trend for mortality, stroke, and pacemaker implantation during early and longer-term follow-up after TAVR. Standardized mortality ratios were higher for TAVR patients younger than 90 years of age compared with expected rates of mortality in an age- and sex-matched Swiss population. (SWISS TAVI Registry; NCT01368250).

Transcatheter Aortic Valve Replacement Programs: Clinical Outcomes and Developments

Transcatheter aortic valve replacement is a relatively recent revolutionary treatment that has now become a standard procedure for treating severe aortic stenosis. In this article, the authors review the clinical history of transcatheter aortic valve replacement, summarize the major clinical trials, and describe the evolution of the technique over time. In doing so, the authors hope to provide a clear and concise review of the history and clinical evidence behind transcatheter aortic valve replacement.

Risk stratification for nonagenarians undergoing transcatheter aortic valve replacement

BACKGROUND

There are disparate data on the outcomes of nonagenarians undergoing transcatheter aortic valve replacement (TAVR) compared with younger patients. The purpose of this study is to determine whether the Society of Thoracic Surgeons (STS) score can be used to identify the subset of nonagenarians that are at a significantly higher risk for poor postoperative outcomes after TAVR.

METHODS

A total of 425 patients above the age of 80 underwent elective TAVR between 12/2013 and 2/2018 and were included in this study. Patients were deemed intermediate or high risk based on an STS predicted the risk of surgical mortality score of 3% to 8% and more than 8%, respectively. Differences in postoperative outcomes and/or 6-month mortality between intermediate and high-risk octogenarians and nonagenarians were compared.

RESULTS

Of the 425 patients, 112 (26.4%) patients were nonagenarians, and 313 (73.6%) patients were octogenarians. Fifty-four (48.2%) of the nonagenarians were stratified as high-risk, while 78 (24.9%) of the octogenarians were stratified as high-risk. There were no statistically significant differences in the composite outcomes between intermediate-risk nonagenarians and intermediate-risk octogenarians. In contrast, high-risk nonagenarians were significantly more likely to experience the composite outcome of major perioperative complications and/or 6-month mortality as compared to high-risk octogenarians.

CONCLUSION

Intermediate-risk nonagenarians undergoing TAVR have similar postoperative outcomes compared to intermediate-risk octogenarians. However, high-risk nonagenarian patients undergoing TAVR experience significantly poorer outcomes compared to their octogenarian counterparts. Judicious patient selection for TAVR in this subgroup of patients is therefore warranted.