Quality of life in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: tools and evidence

Aortic stenosis is the most prevalent valvular heart disease requiring intervention, especially in the elderly population. Surgical aortic valve replacement and transcatheter aortic valve implantation (TAVI) are well established treatment options for symptomatic patients with severe aortic stenosis, as they provide a significant survival benefit. Aortic stenosis may have an important impact on patients' quality of life (QoL). However, advanced age, comorbidities and frailty may limit the beneficial effect of aortic stenosis interventions in terms of QoL. Current guidelines mention the importance of frailty and avoiding the futility of interventions, but lack specific indications about decision-making. Also, there are limited data on how to specifically assess QoL in aortic stenosis patients since the most used questionnaires are validated in different populations (i.e. heart failure). The aim of this review is to summarize all the available tools for QoL assessment in patients with aortic stenosis; to report current evidence on the impact of TAVI on QoL; and to discuss the role of frailty and comorbidities in this setting.

Daily Physical Activity Measured by Wearable Smartwatch for Patients Undergoing Transcatheter Aortic Valve Replacement: Insights From the SMART TAVR Study

BACKGROUND

This study aims to evaluate limited data about daily physical activity patterns, influential factors, and their association with 1-year mortality or rehospitalization after transcatheter aortic valve replacement (TAVR) through smartwatches.

METHODS

Consecutive severe aortic stenosis patients undergoing elective transfemoral TAVR in a Chinese tertiary hospital were enrolled from July 2021 to May 2022 and received a Huawei smartwatch at least 1 day before TAVR. The primary outcome was a composite of all-cause mortality or hospital readmission within 1 year. Linear mixed-effects models were applied to determine influential factors of daily step counts, and Cox proportional hazard regression models were to estimate the association between baseline step counts within 1 month since discharge and composite outcome from months 2 to 12. The dose-response association was assessed using restricted cubic spline curves.

RESULTS

A total of 222 participants and 59 469 valid monitoring person-day records were included (mean age, 72.7 years; 61% women). Step counts increased rapidly within the first 2 months (P<0.001), followed by a slower increase for those without composite outcomes (P=0.029) and a gradual decrease for those who developed composite outcomes (P<0.001). In multivariate linear mixed models, a 1-m increase in baseline 6-minute walk test and a 1-month delay after discharge were associated with 4 (95% CI, 1-7) and 170 (95% CI, 145-194) additional step counts, respectively. In restricted cubic spline analysis, the hazard ratio declined progressively until ≈5000 steps per day, after which they leveled. Below 5000 steps, the adjusted hazard ratio of composite outcome associated with each 1000-step count increase was 0.67 (0.50-0.89; P=0.007). However, above 5000 steps, step counts were not significantly associated with the composite outcome (P=0.645), with a hazard ratio of 1.12 (0.70-1.79).

CONCLUSIONS

Daily step counts rapidly increased within the first 2 months post-TAVR. Increased physical activity was associated with a lower risk of 1-year mortality or rehospitalization after TAVR for patients with daily step counts below 5000.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04454177.

Quality of Life Measures in Aortic Stenosis Research: A Narrative Review

BACKGROUND

Elderly patients with aortic stenosis (AS) not only have a reduced life expectancy but also a reduced quality of life (QoL). The benefits of an AS intervention may be considered a balance between a good QoL and a reasonably extended life. However, the different questionnaires being used to determine the QoL were generally not developed for the specific situation of patients with AS and come with strengths and considerable weaknesses. The objective of this article was to provide an overview of the available QoL instruments in AS research, describe their strengths and weaknesses, and provide our assessment of the utility of the available scoring instruments for QoL measurements in AS.

SUMMARY

We identified and reviewed the following instruments that are used in AS research: Short Form Health Survey (SF-36/SF-12), EuroQol-5D (EQ-5D), the Illness Intrusiveness Rating Scale (IIRS), the HeartQoL, the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHF), the MacNew Questionnaire, and the Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ).

KEY MESSAGES

There is no standardized assessment of QoL in patients with AS. Many different questionnaires are being used, but they are rarely specific for AS. There is a need for AS-specific research into the QoL of patients as life prolongation may compete for an improved QoL in this elderly patient group.

Quality of Life Assessment in Patients Undergoing Trans-Catheter Aortic Valve Implantation Using MacNew Questionnaire

The MacNew questionnaire is a disease-specific quality of life measure that has been used in patients with myocardial infarction and heart failure. We aimed to investigate the impact of transcatheter aortic valve implantation (TAVI) on health-related quality of life (HRQoL) using MacNew Questionnaire and identify predictors associated with a change in its score. This was a prospective multi-center study performed across 5 National Health Service hospitals in the United Kingdom performing TAVI between 2016 and 2018. HRQoL was assessed using MacNew Questionnaire, Euro Quality of Life-5D-5L, and Short Form 36 questionnaires collected at baseline, 3-, 6- and 12 months after the procedure. Out of 225 recruited patients, 19 did not have TAVI and 4 withdrew their consent, and hence 202 patients were included. HRQoL was assessed in 181, 161, and 147 patients at 3, 6, and 12 months, respectively. Using MacNew, there was a significant improvement in all domains of HRQoL as early as 3 months after TAVI which was sustained up to 12 months with improved discrimination of change in HRQoL compared with other scales. Poor mobility at baseline and history of myocardial infarction were independent predictors of reduced improvement in HRQoL at 3 months. HRQoL increased in all subgroups of patients including frail ones. In conclusion, the MacNew assessment tool performed well in a representative TAVI cohort and could be used as an alternative disease-specific method for assessing HRQoL change after TAVI.

Effects of Transcatheter Aortic Valve Implantation on Frailty and Quality of Life

Background

Methods

Results

Conclusions

Quality of life outcomes in transcatheter aortic valve replacement patients requiring pacemaker implantation

BACKGROUND

Permanent pacemaker implantation is the most common complication after Transcatheter aortic valve replacement (TAVR) and is associated with worse outcomes and mortality. However, its impact on quality-of-life (QoL) outcomes remains unknown.

METHODS

We included 383 consecutive patients undergoing TAVR from January 2012 to 2016 who completed a baseline Kansas City Cardiomyopathy Questionnaire (KCCQ-12) health survey. The clinical, laboratory, angiographic, QoL, mortality, and occurrence of poor outcomes (KCCQ-12 score < 45 or KCCQ decrease of ≥10 points) were obtained.

RESULTS

The mean age was 83 ± 8 years, 51% were men, and majority were Caucasians (n = 364, 95%). Permanent pacemaker (PPM) was implanted in 11.5% of patients post-TAVR. PPM patients were more likely to have prior conduction disease including RBBB (25% vs 12%, P = .02) and PQ interval >250 ms (11% vs 5%, P = .07). One-month median KCCQ-12 scores were significantly lower among PPM patients (84.7 vs 68.8, P = .04), but did not differ significantly at 1-year (86.5 vs 90.6, P = .5) post-TAVR. Occurrence of poor outcomes did not differ significantly among those with or without PPM at 1 month (11% vs 7%, P = .39) and 1 year (13% vs 9%, P = .45), respectively. However, patients with poor QoL outcomes at 1 month post-TAVR also had significantly worse mortality during follow-up in unadjusted (31.3% vs 4.5%, P < .001) and adjusted (HR = 5.30, 95% [CI: 1.85-15.22, P = .002])analyses, respectively.

CONCLUSION

Permanent pacemaker implantation is associated with short-term reduction in QoL without long-term implications post-TAVR. Patients with poor QoL post-TAVR also have significantly higher mortality.

Functional capacity and health-related quality of life outcomes post transcatheter aortic valve replacement: a systematic review and meta-analysis

Background

transcatheter aortic valve replacement (TAVR) provides prognostic benefit for high surgical-risk patients with severe aortic stenosis (AS), yet the impact to patient outcomes is far less understood.

Method

we performed a systematic review and meta-analysis to evaluate functional capacity and health-related quality of life (HRQoL) outcomes for patients up to 12 months post TAVR. A total of 20 eligible publications, comprising randomised-controlled trials, observational studies and a registry study were identified from electronic databases, including MEDLINE, EMBASE, Cochrane Library and others (inception to February 2017).

Results

the total sample was 2,775 with a mean age of 81.8 ± 2.1 years, more than half (52%) were female and high surgical risk 9.6 ± 4.3% mean STS (Society of Thoracic Surgeons risk model). Post TAVR, patients had significant improvement in functional capacity of >40 m in the 6-minute walk test (6MWT) (95% confidence interval (CI) 9.69-73.28) and a clinically meaningful increase in ability to perform daily physical-based tasks (Duke Activity Status Index (DASI), mean difference (MD) increase 5.42 points, 95% CI 3.16-7.68). HRQoL improved consistently following TAVR regardless of measure used. Significant increases occurred in the physical component summary scores (PCS) of the short form (SF) health surveys (MD increase 10.45 (SF36) and 10.14 (SF12) points).

Conclusion

functional capacity and HRQoL improved substantially following TAVR, despite evolving patient selection criteria, thus TAVR continues to provide a directly beneficial option for severe AS patients.

Durability of quality of life benefits of transcatheter aortic valve replacement: Long-term results from the CoreValve US extreme risk trial

BACKGROUND

For patients with severe aortic stenosis (AS) at extreme surgical risk, transcatheter aortic valve replacement (TAVR) leads to improved survival and health status when compared with medical therapy. Whether the early health status benefits of TAVR in these patients are sustained beyond 1 year of follow-up is unknown.

METHODS AND RESULTS

Six hundred thirty-nine patients with severe AS at extreme surgical risk underwent TAVR in the CoreValve US Extreme Risk Pivotal trial. Health status was evaluated at baseline and at 1, 6, 12, 24, and 36 months using the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Short-Form-12, and the EuroQoL-5D. Analyses were performed using pattern mixture models to account for both death and missing data and were stratified by iliofemoral (IF) and non-iliofemoral (non-IF) access. After TAVR, there was substantial health status improvement in disease-specific and generic scales by 6 to 12 months. Although there were small declines in health status after 12 months, the initial benefits of TAVR were largely sustained through 3 years for both IF and non-IF cohorts (change from baseline in KCCQ Overall Summary score 19.0 points in IF patients and 14.9 points in non-IF patients; P<.01 for both comparisons). Among surviving patients, clinically meaningful (≥10 point) improvements in the KCCQ Overall Summary Score at 3 years were observed in 85.0% and 83.4% of IF and non-IF patients respectively.

CONCLUSIONS

Among extreme risk patients with severe AS, TAVR resulted in large initial health status benefits that were sustained through 3-year follow-up. Although late mortality was high in this population, these findings demonstrate that TAVR offers substantial and durable health status improvements for surviving patients.

Comparison of Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement to Improve Quality of Life in Patients >70 Years of Age with Severe Aortic Stenosis

OBJECTIVE

Transcatheter aortic valve implantation has recently been used in the treatment of severe aortic valve stenosis, particularly in patients with high mortality and morbidity rates for open surgery. The purpose of this study was to compare quality of life in patients over 70 years of age undergoing surgical or transcatheter aortic valve implantation, before the procedure and in the early post-procedural period.

METHODS

Seventy-nine patients were included in the study, 38 (48.1%) male and 41 (51.9%) female. Mean age of patients was 74.3±5.2 (70-91) years. The surgical aortic valve replacement group consisted of 51 (64.6%) patients and the transcatheter aortic valve replacement group of 28 (35.4%). Quality of life data before the procedure and at the 3rd month postoperatively in patients aged 70 years and older undergoing surgical or transcatheter aortic valve implantation were assessed using the 36-item Short Form Health Survey form.

RESULTS

Positive increases in physical task difficulty (13.2±9.8vs. 5.1±7.3) (P=0.001), emotional task difficulty (14.4±11.9 vs.8.5±6.4) (P=0.035), and mental health (0.4±10.4 vs. 9.6±15.1) (P=0.001; P<0.01) scores in patients undergoing transcatheter aortic valve replacement were significantly higher compared to the surgical aortic valve replacement group. No statistically significant difference was determined between the groups in terms of pain, vitality, social function, physical function or general health scores in the preoperative and postoperative periods.

CONCLUSION

The positive increase in quality of life parameters in the transcatheter aortic valve implantation group at the 3rd month postoperatively was significantly higher compared to the surgical aortic valve replacement group.

Assessment of quality of life in patients after surgical and transcatheter aortic valve replacement

OBJECTIVES

Transcatheter aortic valve implantation (TAVI) and minimally invasive aortic valve replacement (mini-thoracotomy, mini-sternotomy, MIAVR) have become an appealing alternative to conventional surgical (SAVR) treatment of severe aortic stenosis (AS) in high-risk patients.

BACKGROUND

Aim of the study was to evaluate the quality of life (QoL) in patients with AS and treated with transfemoral TAVI, SAVR, mini-thoracotomy and mini-sternotomy.

METHODS

One hundred and seventy-three patients with symptomatic AS were enrolled in 2011-2013. TAVI group consisted of 39 patients (22.5%), mini-sternotomy was performed in 44 patients (25.5%), mini-thoracotomy in 50 (29%), and AVR in 40 patients (23%). QoL was assessed perioperatively, 12 and 24 months after aortic valve replacement (AVR) by Minnesota Living with Heart Failure Questionnaire (MLHFQ) and EQ-5D-3L.

RESULTS

Median follow-up was 583.5 (IQR: 298-736) days. Improvement of health status after procedure in comparison with pre-operative period was significantly more often reported after TAVI in perioperative period (90.3%; P = 0.004) and 12 months after procedure (100%, P = 0.02). Global MLHFQ, physical and emotional dimension score at 30-day from AVR presented significant improvement after TAVI in comparison with surgical methods (respectively: 8.3(±8.6), P = 0.003; 4.1(±5.9), P = 0.01; 1.5(±2.6), P = 0.005). Total MLHFQ score was significantly lower (better outcome) in TAVI patients 1 year after procedure (4.8(±6.8), P = 0.004), no differences in somatic and emotional component were found. No differences were found in MLHFQ score 24 months after AVR. Data from EQ-D5-3L questionnaire demonstrated significant improvement of QoL at 30-day follow-up after TAVI in comparison with surgical methods (1.2(±1.7), P = 0.0008).

CONCLUSIONS

TAVI improves QoL in perioperative and 12 months observation in comparison with mini-thoracotomy, mini-sternotomy and SAVR. Improvement in QoL was obtained in both generic and disease specific questionnaires. © 2016 Wiley Periodicals, Inc.

Feasibility of sheathless transfemoral aortic valve implantation in patients with small access vessel diameters

OBJECTIVES

We intended to show feasibility of sheathless transfemoral aortic valve implantation in patients with small access vessel diameters.

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has emerged as a valid treatment option in patients with aortic valve stenosis who are poor candidates for surgical aortic valve replacement. Few patients, who cannot undergo transfemoral or transsubclavian aortic valve implantation due to small access vessel diameters, are not suitable for transapical or direct aortic valve implantation, either.

METHODS

In more than 700 transcatheter aortic valve implantations since 2008 we identified 17 patients who had to be excluded from transfemoral valve implantation due to vessel diameters <6 mm and who were no candidates for transapical or direct aortic implantation. We performed CoreValve™ implantations in these patients without the required 18F sheath to cross the vessels despite their small size (4.6-5.9 mm).

RESULTS

Sixteen sheathless implantations were successful. In all 17 patients, bleeding during the procedure due to the smaller delivery catheter was minimal. Sixteen patients had a successful access site closure at the end of the procedure.

CONCLUSIONS

Sheathless implantation of a self-expanding aortic valve can be safely considered in selected patients with access vessel diameters below 6 mm, if transapical or direct aortic implantation is not suitable.

Beyond adding years to life: health-related quality-of-life and functional outcomes in patients with severe aortic valve stenosis at high surgical risk undergoing transcatheter aortic valve replacement

Aortic valve stenosis (AVS) is the most frequent acquired valvular heart disease in western industrialized countries and its prevalence considerably increases with age. Once becoming symptomatic severe AVS has a very poor prognosis. Progressive and rapid symptom deterioration leads to an impairment of functional status and compromised healthrelated quality-of-life (HrQoL) simultaneously. Until recently, surgical aortic valve replacement (SAVR) has been the only effective treatment option for improving symptoms and prolonging survival. Transcatheter aortic valve replacement (TAVR) emerged as an alternative treatment modality for those patients with severe symptomatic AVS in whom the risk for SAVR is considered prohibitive or too high. TAVR has gained clinical acceptance with almost startling rapidity and has even quickly become the standard of care for the treatment of appropriately selected individuals with inoperable AVS during recent years. Typically, patients currently referred for and treated by TAVR are elderly with a concomitant variable spectrum of multiple comorbidities, disabilities and limited life expectancy. Beyond mortality and morbidity, the assessment of HrQoL is of paramount importance not only to guide patient-centered clinical decision-making but also to judge this new treatment modality. As per current evidence, TAVR significantly improves HrQoL in high-surgical risk patients with severe AVS with sustained effects up to two years when compared with optimal medical care and demonstrates comparable benefits relative to SAVR.

Along with a provision of a detailed overview of the current literature regarding functional and HrQoL outcomes in patients undergoing TAVR, this review article addresses specific considerations of the HrQoL aspect in the elderly patient and finally outlines the implications of HrQoL outcomes for medico-economic deliberations.

Functional status and quality of life after transcatheter aortic valve replacement: a systematic review

BACKGROUND

The functional and quality-of-life benefits of transcatheter aortic valve replacement (TAVR) have not been established.

PURPOSE

To evaluate the changes in functional status and quality of life after TAVR.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1 January 2002 to 30 September 2013.

STUDY SELECTION

Studies of TAVR that reported the New York Heart Association (NYHA) class, Short Form-12/36 Health Survey physical and mental component summary (points), or other measures of functional status.

DATA EXTRACTION

Two reviewers independently extracted the mean change (follow-up minus baseline) in primary outcomes. Because of substantial heterogeneity, data were not pooled; the range of mean change was summarized.

DATA SYNTHESIS

We identified 60 observational studies (56 pre–post comparison and 4 head-to-head comparative studies) and 2 randomized, controlled trials (11 205 patients). Most studies showed a clinically important decrease in NYHA class at 6 to 11 months (range, -0.8 to -2.1 classes) and 12 to 23 months (range, -0.8 to -2.1 classes). The improvement in the Short Form-12/36 Health Survey physical component score was clinically important over 12 months (range, 4.9 to 26.9 points), and the change in mental component score was smaller (range, 1.0 to 8.9 points).Clinically important improvements were seen in other disease-specific measures but were less consistently seen in general health measures.

LIMITATIONS

Comparative evidence is limited by few head-to-head studies. Survivor bias may have overestimated the benefits.

CONCLUSION

Transcatheter aortic valve replacement provides clinically important benefits in physical function and disease-specific measures of quality of life but modest benefits in psychological and general health measures. More comparative studies on functional status and quality of life are needed for informed treatment decision making.

Comprehensive prospective cognitive and physical function assessment in elderly patients undergoing transcatheter aortic valve implantation

OBJECTIVE

Transcatheter aortic valve implantation (TAVI) is occasionally associated with stroke and silent cerebral ischemia, which may affect cognitive and functional performance. The aim of this study was to evaluate the changes in cognitive performance and functional status following TAVI.

METHODS

We performed a comprehensive prospective functional, cognitive and quality of life (QOL) evaluation in consecutive patients who underwent TAVI using the CoreValve device (Medtronic Inc.). The evaluation was performed at baseline and 1 month after the procedure and included the 36-item Short-Form Health Survey for QOL assessment, Mini-Mental State Examination (MMSE), quantitative clock drawing test (Rouleau), color trails test, Cognistat evaluation, Barthel Index and Duke Activity Status Index.

RESULTS

A total of 36 patients completed the full pre- and post-TAVI evaluation. Mean age was 82.2 ± 4.2 years (52.8% men); 94.5% of patients had low functional class (New York Heart Association III/IV), and 13.9% had prior stroke. After the procedure, all patients had improved functional status and valve hemodynamics. At 1 month, there was a significant improvement in the MMSE and Cognistat evaluations (from 25.9 ± 3.3 to 27.6 ± 2.4, p < 0.001, and from 5 ± 1 to 5.7 ± 0.7, p = 0.001, respectively).

CONCLUSIONS

Our preliminary results of a comprehensive assessment of patients undergoing TAVI indicate favorable results for both functional performance and cognitive function early after the procedure.

Surgical aortic valve replacement in very elderly patients aged 80 years and over: evaluation of early clinical outcomes

BACKGROUND

An increasing number of very elderly patients aged ≥80 years will require aortic valve replacement (AVR) for severe aortic stenosis (AS). Many are classified as high-risk surgical candidates. Transcatheter aortic valve implantation (TAVI) has been proposed as an alternative to surgical AVR (SAVR) for high-risk patients. We evaluated early clinical outcomes of very elderly patients undergoing SAVR to optimise TAVI candidate selection.

METHODS

We conducted a retrospective case review of 132 consecutive patients aged ≥80 years undergoing isolated SAVR (49 patients) or combined SAVR/CABG (83 patients) during February 2002-January 2010 at a single tertiary referral hospital. Risk for cardiac surgery was calculated using the logistic EuroSCORE (ES(log)). Mortality and morbidity data were collected for the 30-day postoperative period.

RESULTS

Thirty-day mortality rate was 8.3% for patients undergoing SAVR (6.1% for isolated SAVR and 9.6% for SAVR/CABG). Permanent stroke occurred in 3.8% and renal insufficiency in 7.6% of the cohort. Thirty-five percent of patients had left ventricular ejection fraction <50%, 67% had advanced symptoms (NYHA class III or IV), and 42% of patients were stratified as high-risk (ES(log)≥20%).

CONCLUSIONS

SAVR can be performed in very elderly patients with acceptable operative morbidity and mortality. The outcomes at our institution are comparable to contemporary SAVR and TAVI outcomes.