Impact of frailty on clinical outcomes in elderly patients after transcatheter aortic valve replacement

It remains unclear whether elderly patients with compressive cervical myelopathy can be expected to experience a promising surgery-related outcome after undergoing expansive laminoplasty. The purposes of this study were to evaluate the efficacy of expansive laminoplasty in elderly patients with cervical myelopathy due to multisegmental spondylotic canal stenosis and to analyze the effect of preoperative prognostic factors on outcome in elderly compared with younger patients. The authors reviewed the cases of 22 elderly (> 70 years of age) and 39 younger patients in whom expansive open-door laminoplasty was performed for cervical myelopathy due to multisegmental spondylotic canal stenosis. The pre- and 12-month postoperative clinical symptoms were evaluated using the Japanese Orthopaedic Association (JOA) disability scale. Factors affecting the clinical outcome were statistically analyzed by evaluating the recovery rate calculated from the JOA scale. There were no significant differences in the mean value of the preoperative factors, especially preoperative duration of symptoms and severity of preoperative disease, between the elderly and younger patient groups. In all patients, age at the time of the operation was shown to exert no significant influence on clinical outcome. The mean recovery rate was 58.8% in the elderly group and 61.8% in the younger group, and there was no significant intergroup difference. Improvement or attenuation in impaired upper- and lower-leg motor function was shown in all patients as was an absence in decline of sensory impairment of the extremities. In the elderly group, both the duration of symptoms and the severity of canal stenosis significantly (p < 0.05) affected the clinical outcome. In the younger group, the severity of preoperative symptoms had a significant (p < 0.05) influence on clinical outcome, whereas duration of the symptoms did not appreciably affect clinical improvement. Open-door expansive laminoplasty showed a promising effect on clinical outcome in elderly and younger patients with multisegmental cervical canal stenosis. Significant predictive factors for clinical outcome in the elderly patients were the duration of symptoms and the severity of stenosis, which may involve the static factor causing the cervical myelopathy. To improve the elderly patients' disability, surgery must be performed as early as possible before irreversible changes in the spinal cord develop.

BackgroundThis study investigates the association between red cell distribution width to albumin ratio (RAR) and clinical outcomes in elderly sepsis patients.MethodsThis study investigates the association between red cell distribution width to albumin ratio (RAR) and clinical outcomes in elderly sepsis patients. Methods: Using the eICU-CRD (2014–2015), 5,976 sepsis patients aged≥60 years were stratified into RAR quartiles at ICU admission: Q1 (≤5.28), Q2 (5.29–6.37), Q3 (6.38–7.87), and Q4 (7.88–15.0), with Q1 as the reference category. The primary outcome was 28-day hospital mortality, while secondary outcomes included ICU mortality, 90-day hospital mortality, and lengths of ICU and hospital stays. Multivariable regression analysis and spline curves from the generalized additive model were applied to assess the association between RAR and clinical outcomes. Kaplan–Meier survival analysis illustrated cumulative hospital mortality across RAR quartiles.ResultsThe 28-day hospital, ICU, and 90-day hospital mortality were 17.4, 10.9, 17.8%, respectively, with ICU and hospital stays of 2.9 (1.8–5.1) and 7.1 (4.6–11.7) days. Compared to Q1, Q4 exhibited significantly increased risks of 28-day hospital mortality (adjusted odds ratio [OR]: 2.95, 95% confidence interval [CI]: 2.28–3.80), ICU mortality (adjusted OR: 2.06, 95% CI: 1.52–2.78), 90-day hospital mortality (adjusted OR: 3.03, 95% CI: 2.35–3.90), and prolonged ICU (β: 0.89, 95% CI: 0.42, 1.36) and hospital stays (β: 1.64, 95% CI: 0.93, 2.36). Generalized additive model revealed linear relationship between RAR and mortality. Kaplan–Meier survival analysis demonstrated higher mortality with elevated RAR quartiles.ConclusionElevated baseline RAR is independently associated with adverse clinical outcomes in elderly sepsis patients, suggesting it may be a valuable tool for early risk stratification and personalized therapeutic interventions.

Coagulation Biomarkers and Clinical Outcomes in Elderly Patients With Nonvalvular Atrial Fibrillation: ANAFIE Subcohort Study

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Reviews. This series will summarize the most important manuscripts, as selected by the Editor, which have been published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes as well as general cardiology audience. The studies included in this article represent the most significant research in the area of valvular heart disease. ( Circ Cardiovasc Quality and Outcomes . 2012;5:-e103.) In recent years, no field of clinical cardiology has experienced a great influx of transformational therapeutic options as has the area of valvular heart disease. Treatment of severe aortic stenosis (AS) has been revolutionized by transcatheter aortic valve replacement (TAVR), which has been shown to improve life expectancy and functional outcomes in patients with inoperable AS1,2 and to have short-term outcomes comparable to surgical aortic valve replacement (AVR) in patients at high perioperative risk.3,4 Analogously, mitral valve disease has been amenable to percutaneous valve replacement,5,6 as well as clipping procedures7 that can substantively reduce severe mitral regurgitation (MR) and improve functional outcomes. Even right-sided heart disease involving valves in pulmonary8,9 and tricuspid10 positions has been treated successfully with endovascular techniques. Yet, even with this growing focus on percutaneous valvular interventions, open surgical techniques remain the dominant treatment strategies and standard of care for most advanced lesions. Surgical valve repair and replacement account for 10% to 20% of all cardiac surgical procedures,11–13 approximately two thirds of which are for AS.11–13 For patients undergoing surgery, there remains considerable debate about risk stratification,14 intraoperative technique,15 and postoperative …

Japan has become an aging society, resulting in an increased prevalence of coronary artery disease. However, clinical outcomes of elderly Japanese patients after percutaneous coronary intervention (PCI) remain unclear. Of the 15,227 patients in the Shinken Database, a single-hospital-based cohort of new patients, 1,214 patients who underwent PCI, was evaluated to determine the differences in clinical outcomes between the elderly (≥75 years) (n = 260) and the non-elderly (<75 years) (n = 954) patients. A major adverse cardiac event (MACE) was defined as a composite end point, including all-cause death, myocardial infarction (MI), and target lesion revascularization. Male gender and obesity were less common, and the estimated glomerular filtration rate (eGFR) was significantly lower in the elderly than in the non-elderly. Left ventricular ejection fraction (LVEF) was comparable between these groups. Left main trunk disease and multivessel disease were more common in the elderly than in the non-elderly group. Occurrence of MACE was frequent, and the incidences of all-cause death, cardiac death, and the admission rate for heart failure were significantly higher in the elderly patients. Multivariate analysis showed that prior MI, low eGFR, and poor LVEF were independent predictors for all-cause death in the elderly patients. Elderly patients had worse clinical outcomes than the non-elderly patients. Low eGFR and LVEF were independent predictors of all-cause death after PCI, suggesting that left ventricular dysfunction and renal dysfunction might synergistically contribute to the adverse clinical outcomes of the elderly patients undergoing PCI.Electronic supplementary materialThe online version of this article (doi:10.1007/s00380-013-0339-9) contains supplementary material, which is available to authorized users.

IntroductionCommunity‐acquired pneumonia (CAP) is the major cause of infection‐related mortality worldwide. Patients with CAP frequently present with admission hyperglycemia.ObjectivesThe aim of this study was to evaluate the association between admission blood glucose (ABG) level and clinical outcomes in elderly CAP patients (≥80 years of age) with or without diabetes.MethodsIn this single center retrospective study, 290 elderly patients diagnosed with CAP were included. Demographic and clinical information were collected and compared. The associations between admission blood glucose level and the 30‐day mortality as well as intensive care unit (ICU) admission and invasive mechanical ventilation (IMV) in elderly CAP patients with or without diabetes were assessed.ResultsOf the 290 eligible patients with CAP, 159 (66.5%) patients were male, and 64 (22.1%) had a known history of diabetes at hospital admission. After adjusting for age and sex, the logistic regression analysis had identified several risk factors that might be associated with clinical outcomes in elderly patients with CAP. Multivariable logistic regression analysis revealed that admission glucose level > 11.1 mmol/L was significant associated with ICU admission, IMV, and 30‐day mortality both in non‐diabetic and diabetic patients. Furthermore, Kaplan–Meier analysis indicated that patients with higher admission glucose level were correlated statistically significantly with 30‐day mortality in patients with CAP (P < 0.001).ConclusionAdmission blood glucose is correlated with 30‐day hospital mortality, ICU admission, and IMV of CAP in elderly patients with and without diabetes. Specially, admission glucose > 11.1 mmol/L was a significant risk factor for 30‐day hospital mortality.

IntroductionThis study to assess the associations between different rivaroxaban doses and clinical outcomes in elderly NVAF patients in a real-world setting, and to explore factors influencing dose selection.MethodsA retrospective analysis was conducted on elderly patients (aged ≥65 years) diagnosed with NVAF and hospitalized at the Ninth People’s Hospital of Zhengzhou between 1 January 2022, and 31 December 2022. All patients received rivaroxaban therapy. Based on the prescribed dose, patients were categorized into a standard-dose group (15–20 mg/day) and a low-dose group (10 mg/day) groups based on the prescribed dose. Clinical outcomes within 12 months post-discharge were collected via follow-up, including readmission records and telephone interviews.ResultsA total of 214 elderly patients with NVAF were included in the study. The mean age was 79.2 ± 8.2 years in the low-dose group and 75.4 ± 8.0 years in the standard-dose group (P = 0.001). There were no significant differences were observed between the two groups in terms of sex (P = 0.298), CHA2DS2-VASc score (P = 0.783) and HAS-BLED score (P = 0.586). The low-dose group had a significantly higher proportion of older patients (P = 0.001) and individuals with a history of bleeding (21.42% vs. 7.79%, P = 0.004). Follow-up revealed no statistically significant differences between the two groups in thromboembolic events (P = 0.308) and bleeding events (P = 0.187). However, the standard-dose group had a higher 12-month cumulative survival rate (HR = 0.61; 95% CI: 0.39–0.95; log-rank; P = 0.03). After propensity score matching to balance baseline features, there was no difference between the two groups. Multivariate logistic regression analysis identifiedthe following as significant factors influencing dose selection: age (OR = 0.95, 95% CI: 0.91–0.98, P = 0.004), history of bleeding (OR = 0.36, 95% CI:0.14–0.95, P = 0.038), and estimated glomerular filtration rate (eGFR) (OR = 0.99, 95% CI: 0.97–1.00, P = 0.019).ConclusionThis retrospective study found that low-dose rivaroxaban was not significantly different from the standard dose in terms of thromboembolic events, bleeding, and all-cause mortality in elderly patients with NVAF. Although the safety profiles appeared similar between the two groups, the standard dose was associated with a higher cumulative survival rate in the unadjusted analysis. However, this observed survival difference may be influenced by baseline confounders, such as age and bleeding history. These findings suggest an association and support the need for further investigation into flexible anticoagulation strategies in clinical practice. Age, bleeding history, and renal function must be carefully considered when individualizing treatment.

An aging society means that the number of elderly patients with cancer is predicted to rise in the future. Hepatocellular carcinoma (HCC) usually develops in patients with hepatitis B virus infection, hepatitis C virus infection, or alcoholic liver disease. The risk of developing HCC is also known to be age-dependent and elderly patients sometimes present with HCC. The increased longevity of the population thus means that more elderly HCC patients are to be expected in the coming years. In general, many elderly patients are not receiving optimal therapy for malignancies, because it is often withheld from them because of perceived minimal survival advantage and the fear of potential toxicity. Comprehensive data with regard to treatment of elderly patients with HCC are currently limited. Furthermore, current guidelines for the management of HCC do not satisfy strategies according to age. Thus, there is urgent need for investigation of safety and clinical outcomes in elderly patients who receive therapy for HCC. In this review, we primarily refer to current knowledge of clinical characteristics and outcome in elderly patients with HCC who underwent different treatment approaches (i.e., surgical resection, liver transplantation, locoregional therapies, and molecular-targeting therapy).

Background Although surgical aortic valve replacement (SAVR) is recommended for symptomatic severe aortic stenosis (AS) patients at low surgical risk, there is a growing need for an expansion of transcatheter aortic valve replacement (TAVR) as an alternative to SAVR for elderly AS patients at low operative risk. Purpose We tried to compare the long-term clinical outcomes of TAVR versus SAVR in elderly AS patients (≥80 years old) at low surgical risk. Methods We consecutively enrolled 261 elderly patients (131 men; 83±3 years of age) with symptomatic severe AS and EuroSCORE II &lt;4%, who underwent SAVR or TAVR from 2010 to 2018. Heart Team made the decision between SAVR and TAVR according to the individual patient's preference and characteristics. SAVR was performed on 93 patients (SAVR group), whereas TAVR was chosen for 168 patients (TAVR group). The primary end point was cardiac mortality including procedure-related death, and the secondary end point was all-cause death and cardiovascular event. Results Baseline characteristics were similar between the two groups, but the TAVR group was significantly older than the SAVR group (83±3 vs 82±2 years; p&lt;0.01). Device was successfully implanted in all the patients and there was 1 in-hospital mortality in the TAVR group and 3 in-hospital mortalities in the SAVR group (p=0.13). During a median follow-up of 24 months (IQR, 9–45 months), there were 22 deaths (13.1%) including 8 cardiac deaths (4.8%) in the TAVR group and 16 deaths (17.2%) including 9 cardiac deaths (9.7%) in the SAVR group. The rates of the primary and secondary end points were similar between two groups in the overall cohort and the propensity score-matched cohort (table). On subgroup analysis according to the presence of coronary artery disease (CAD), the only independent variable associated with cardiac mortality, the SAVR group had a significantly higher cardiac mortality rate than the TAVR group (15±7% vs 7±6% at 5 years, p=0.048) in 185 (71%) patients without CAD, whereas there was no significant difference among those with CAD. Harzard ratio for clinical outcomes TAVR (n=168) SAVR (n=93) Overall cohort TAVR (n=76) SAVR (n=76) PS-matched cohort HR (95% CI) p value HR (95% CI) p value Cardiac mortality 8 9 0.65 (0.25–1.71) 0.386 2 7 0.34 (0.07–1.61) 0.173 All-cause mortality 22 16 1.08 (0.56–2.08) 0.831 6 12 0.86 (0.30–2.43) 0.774 Cardiovascular event* 18 12 1.09 (0.52–2.28) 0.826 6 10 0.72 (0.26–1.98) 0.525 *Cardiovascular event was defined as the composite of cardiac mortality, hospitalization for heart failure, stroke, myocardial infarction, and reoperation. Conclusion In elderly AS patients at low surgical risk, TAVR was similar to SAVR with respect to long-term clinical outcomes. TAVR should be considered a treatment option for elderly patients who refuse to undergo surgery despite low risk.

Background: The reply of question of “which coronary artery bypass grafting (CABG) technique is superior in elderly patients, off-pump or on-pump CABG surgery?” is controversial. We aimed to compare the early clinical outcomes in elderly patients undergoing off-pump and on-pump CABG. Methods: From January 2009 to January 2015, 344 elderly patients (aged 70 or older) underwent off-pump (n = 137) or on-pump (n = 207) CABG. Patients’ medical records were retrospectively reviewed, and their baseline preoperative characteristics, operative data and postoperative outcomes were analyzed, thereby a comparison of early outcomes between off-pump and on-pump patients was performed. Results: Mean age of patients was 74.4 ± 3.8 years. Both groups were statistically similar in terms of baseline preoperative characteristics. Number of distal bypass was significantly lower in off-pump group than in on-pump group. Postoperative length of intensive care unit and hospital stay were similar between two groups. Amounts of transfused blood products were significantly lower in off-pump CABG group. There were no significant differences in terms of postoperative complications and mortality between two groups. Conclusions: Our results did not reveal a significant benefit of either surgical technique with respect to early-term clinical outcomes in elderly CABG patients. Further investigations are needed to determine whether off-pump CABG is superior than on-pump CABG in elderly patients.

alnutrition is one of the hallmarks of frailty in elderly patients and a predictor of worse outcomes in elderly patients with severe aortic valve stenosis. 1In this context, Ishizu et al 2 present in this issue of the Journal of the American Heart Association (JAHA) their analyses on prevalence and prognostic value of the Controlling Nutritional Status (CONUT) score, Geriatric Nutritional Risk Index (GNRI), and Prognostic Nutritional Index for malnutrition assessment of Japanese elderly patients at high surgical risk undergoing transcatheter aortic valve implantation (TAVI).They found that malnourishment in their population was common and associated with increased mortality after TAVI regardless of the nutrition index used and irrespective of age, sex, body mass index, frailty, kidney function, and left ventricular ejection fraction.This phenomenon had already been observed by the OCEAN-TAVI (Optimized Transcatheter Valvular Intervention-TAVI) investigators, 3 who found nutritional status as a surrogate marker for predicting worse clinical outcomes after TAVI.While one may argue that this finding might apply only to this select population (only Japanese and very old patients with a mean age >80 years) with a well-defined risk profile (only at high risk), the current evidence shows that patients with different risk profiles (not only those at high risk) and other Asian and Western populations are under the negative impact of malnutrition as well.

Whether the level of education is associated with anticoagulation quality and clinical outcomes in patients with acute venous thromboembolism (VTE) is uncertain. We thus aimed to investigate the association between educational level and anticoagulation quality and clinical outcomes in elderly patients with acute VTE. We studied 817 patients aged ≥65 years with acute VTE from a Swiss prospective multicenter cohort study (09/2009-12/2013). We defined three educational levels: 1) less than high school, 2) high school, and 3) post-secondary degree. The primary outcome was the anticoagulation quality, expressed as the percentage of time spent in the therapeutic INR range (TTR). Secondary outcomes were the time to a first recurrent VTE and major bleeding. We adjusted for potential confounders and periods of anticoagulation. Overall, 56% of patients had less than high school, 25% a high school degree, and 18% a post-secondary degree. The mean percentage of TTR was similar across educational levels (less than high school, 61%; high school, 64%; and post-secondary, 63%; P = 0.36). Within three years of follow-up, patients with less than high school, high school, and a post-secondary degree had a cumulative incidence of recurrent VTE of 14.2%, 12.9%, and 16.4%, and a cumulative incidence of major bleeding of 13.3%, 15.1%, and 15.4%, respectively. After adjustment, educational level was neither associated with anticoagulation quality nor with recurrent VTE or major bleeding. In elderly patients with VTE, we did not find an association between educational level and anticoagulation quality or clinical outcomes.

BackgroundThe optimal timing for initiating dialysis in end-stage renal disease (ESRD) is controversial, especially in the elderly.Methods665 patients ≥65 years old who began dialysis from August 2008 to February 2015 were prospectively enrolled in the Clinical Research Center for End-Stage Renal Disease cohort study. Participants were divided into 2 groups based on the median estimated glomerular filtration rate at the initiation of dialysis. Propensity score matching (PSM) was used to compare the overall survival rate, cardiovascular events, Kidney Disease Quality of Life Short Form 36 (KDQOL-36) results, Karnofsky performance scale values, Beck’s depression inventory values, and subjective global assessments.ResultsThe mean patient age was 72.0 years, and 61.7% of the patients were male. Overall, the cumulative survival rates were lower in the early initiation group, although the difference was not significant after PSM. Additionally, the survival rates of the 2 groups did not differ after adjusting for age, sex, Charlson comorbidity index and hemoglobin, serum albumin, serum calcium and phosphorus levels. Although the early initiation group showed a lower physical component summary score on the KDQOL-36 3 months after dialysis, the difference in scores was not significant 12 months after dialysis. Furthermore, the difference was not significant after PSM. The Karnofsky performance scale, Beck’s depression inventory, and subjective global assessments were not significantly different 3 and 12 months after dialysis initiation.ConclusionsThe timing of dialysis initiation is not associated with clinical outcomes in elderly patients with ESRD.

ObjectiveThis study aims to construct and verify Nomogram prediction model for clinical outcomes of elderly patients with gastric cancer after surgery, which is based on multiple factors such as peripheral blood neutrophil to lymphocyte ratio (NLR), tumor burden and nutritional status.MethodsA total of 189 elderly patients with gastric cancer who received surgical treatment in our hospital from January 2019 to December 2024 were included in the study. They were divided into a training set (n=132) and a validation set (n=57) according to the ratio of 7:3. The data including age, gender, body mass index (BMI), smoking history, drinking history, comorbidities, tumor location, size, histological type, differentiation degree, TNM stage, lymph node metastasis, and preoperative NLR value were collected. After single-factor and multi-factor analysis, the risk factors influencing the postoperative clinical outcome were screened, and the Nomogram model was constructed, evaluated and validated. The decision curve analysis was used to evaluate the clinical value of the model.ResultsThere were 46 cases (34.85%) with adverse clinical outcomes in the training set and 20 cases (35.09%) with adverse clinical outcomes in the validation set. Multivariate Logistic regression analysis showed that NLR, BMI, tumor size, lymph node metastasis, carcinoembryonic antigen (CEA), and age were the independent influencing factors for adverse clinical outcomes of elderly patients after gastric cancer surgery (all P < 0.05). The calibration degree and prediction performance of the nomogram model in the training set and the validation set were good. The C-index index was 0.806 and 0.879, respectively. The calibration curves showed that the average absolute errors of the predicted values and the true values were 0.172 and 0.110, respectively. The Hosmer-Lemeshow test results were χ2 = 16.669, P=0.034 and χ2 = 5.653, P=0.686, respectively. AUC values were 0.802(95% CI: 0.708-0.895) and 0.888(95% CI: 0.757-1.000), respectively, with sensitivity and specificity of 0.889, 0.650, and 0.900 and 0.654, respectively.ConclusionThe NLR-based Nomogram model is useful for predicting the postoperative clinical outcomes of elderly patients with gastric cancer, but it needs to be verified by further large-sample multi-center research.

IntroductionAortic stenosis (AS) is treated with either transcatheter aortic valve replacement (TAVR) or Surgical aortic valve replacement (SAVR). However, limited data exist to study the postoperative clinical outcomes in patients with AS and chronic kidney disease (CKD). The objective of this study is to compare TAVR and SAVR postoperative clinical outcomes in patients with AS and CKD.MethodsAccording to PRISMA guidelines, a comprehensive search was conducted across various databases such as PubMed, EMBASE, Scopus, and Google Scholar. Original studies that compared the clinical outcomes between TAVR and SAVR in patients with underlying CKD were included in the study.ResultsTwenty-three studies with 69 017 patients with chronic kidney disease who underwent TAVR or SAVR were included in this study. Patients who underwent TAVR had significantly lower odds of in-hospital mortality (OR 0.54; 0.32, 0.91; P = 0.02), acute kidney injury [AKI] (OR 0.41; 0.33, 0.51; P < 0.00001), AKI requiring dialysis (OR 0.66; 0.48, 0.91; P = 0.01), and postoperative complications (OR 0.34; 0.23, 0.50; p<0.0001). However, patients who underwent TAVR had significantly higher odds of permanent pacemaker implantation [PPI] (OR 2.69; 1.96, 3.69; P < 0.0001), major vascular complications (OR 2.56; 1.09, 5.99; P = 0.03).ConclusionIn patients with AS and CKD, TAVR is associated with significantly lower in-hospital mortality, a reduced incidence of acute kidney injury, and fewer postoperative complications compared to SAVR. However, TAVR carries higher risks of pacemaker implantation and major vascular complications, highlighting the importance of individualized risk assessment and considering TAVR as a favorable alternative to SAVR in appropriately selected CKD patients.