Abstract
BackgroundFew studies have measured frailty as a potential reason for foregoing transcatheter aortic valve replacement (TAVR) in older adults with severe aortic stenosis (AS). This study sought to determine the impact of frailty and other clinician-cited reasons on restricted mean survival time (RMST).MethodsAn analysis of the McGill Frailty Registry was conducted between 2014 and 2018 at the McGill University Health Center Structural Valve Clinic. Consecutive nonsurgical patients referred for TAVR were included. In those that underwent balloon aortic valvuloplasty or medical management, the primary clinician-cited reason for foregoing TAVR was codified. Vital status was ascertained at 1 year and analysed using RMST and Kaplan-Meier analyses.ResultsThe study consisted of 373 patients with a mean age of 82.4 years, of which 233 underwent TAVR and 140 did not. Patients who did not undergo TAVR were more likely to be nonagenarians, with left ventricular dysfunction, chronic kidney disease, dementia, disability, depression, malnutrition, and frailty. The primary clinician-cited reason was: comorbidity in 34%, frailty in 23%, procedural feasibility and risks in 16%, and mild or unrelated symptoms in 27%. Compared to the TAVR group, 1-year RMST was reduced by 2.0 months in the medical management group (95% CI 1.2, 2.7) and by 1.1 months in the valvuloplasty group (95% CI -0.2, 2.5).ConclusionsPatients with severe AS referred for TAVR may never undergo the procedure on the basis of comorbidity, frailty, procedural issues, and symptoms. The best treatment decision is one that follows from multi-disciplinary assessment encompassing frailty.
Highlights
Few studies have measured frailty as a potential reason for foregoing transcatheter aortic valve replacement (TAVR) in older adults with severe aortic stenosis (AS)
PROM scores they were older, more likely to be nonagenarians, more likely to have left ventricular dysfunction, chronic kidney disease, cognitive impairment, disability for activities of daily living, depression, malnutrition, and frailty according to various scales (Tables 1 and 2)
The mean Essential Frailty Toolset (EFT) score was 2.3 ± 1.1 vs. 1.6 ± 1.1 out of 5 in patients who did not proceed vs. proceeded with TAVR, respectively (P < 0.001)
Summary
Few studies have measured frailty as a potential reason for foregoing transcatheter aortic valve replacement (TAVR) in older adults with severe aortic stenosis (AS). Transcatheter aortic valve replacement (TAVR) has emerged as a less invasive option that was shown to be safe and superior to medical therapy for very high-risk older patients with severe symptomatic AS. The procedural success rate has exceeded 95% and the 30-day and 1-year mortality rates have been estimated to be 5.5% and 23.0%, respectively [3]. Despite these encouraging metrics, certain patients are evaluated and judged not to be good candidates for the TAVR procedure. We sought to compare patients who proceeded with TAVR with those that did not to better understand the reasons cited by clinicians and patients for arriving at their decision and to determine the impact of these reasons on subsequent survival
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