Clinical outcomes of transcatheter aortic valve implantation (TAVI) in nonagenarians from the optimized catheter valvular intervention-TAVI registry

Estimated prevalence of frailty and prefrailty in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and proportional meta-analysis

BACKGROUND

The aging population has led to an increasing number of older patients undergoing cardiac surgeries/procedures. Frailty and prefrailty have emerged as important prognostic indicators among these patients. This proportional meta-analysis estimated the prevalence of frailty and prefrailty among patients undergoing cardiac surgery.

METHODS

We searched seven electronic databases for observational studies that used validated measure(s) of frailty and reported prevalence data on frailty and/or prefrailty in older patients undergoing coronary artery or valvular surgeries or transcatheter procedures. Meta-analyses were performed using a random-effects model.

RESULTS

One hundred and one articles involving 626,863 patients were included. The pooled prevalence rates of frailty and prefrailty were 28% (95% confidence interval [CI]: 23%-33%) and 40% (95% CI: 31%-50%), respectively, for patients scheduled for open-heart surgeries and 40% (95% CI: 36%-45%) and 43% (95% CI: 34%-53%), respectively, for patients undergoing transcatheter procedures. Frailty measured using a multidimensional approach identified a higher proportion of frail patients when compared with measures solely focused on physical frailty. Older age, female sex, and lower body mass index and hemoglobin concentrations were significantly associated with higher frailty prevalence. Moreover, countries with higher gross domestic product spent on healthcare exhibited a higher frailty prevalence.

CONCLUSION

Frailty represents a considerable health challenge among patients undergoing cardiac surgeries/procedures. Routine screening for frailty should be considered during perioperative care planning.

OLD-TAVR score to predict 2-year mortality in patients aged 75 years and more undergoing transcatheter aortic valve replacement

PURPOSE

Decision-making on transcatheter aortic valve replacement (TAVR) in patients aged 75 years and older is complex. It could be facilitated by the identification of predictors of long-term mortality. This study aimed to identify predictors of 2-year mortality to develop a 2-year mortality risk score.

METHODS

Cohort study of consecutive patients aged ≥ 75 years who underwent TAVR after a comprehensive geriatric assessment (CGA) at our university hospital between 2012 and 2019. Predictors of 2-year mortality were determined using multivariable Cox regression. A point-based predictive model was developed based on risk factors and subsequently internally validated by fivefold cross-validation.

RESULTS

The 345 patients (median age 87 years, 54% women) were fit/vulnerable (32%), mildly frail (37%), or moderately/severely frail (31%). The overall 2-year mortality rate was 26%, predicted by atrial fibrillation, hemoglobin ≤ 10 g/dL, age ≥ 87 years, BMI ≤ 24, eGFR ≤ 50 ml/min, and moderate/severe frailty. The risk score (range 0-12), named OLD-TAVR score, for 2-year mortality showed good discriminative power (AUC 0.70) and remained consistent after fivefold cross-validation (cvAUC 0.69). A risk score ≥ 8 (prevalence 20%) predicted a 45% (95%CI: 34-58%) two-year mortality, with high specificity (86%) and good positive predictive power (+ LR 2.43).

CONCLUSION

A 2-year mortality risk score (OLD-TAVR score) for very old patients undergoing TAVR was developed based on six bio-clinical items. A score ≥ 8 identified patients in whom 2-year mortality was very high and thereby the TAVR futile.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

Study protocol B403, 26/09/2022, retrospectively registered.

The Clinical Frailty Scale (CFS) employment in the frailty assessment of patients suffering from Non-Communicable Diseases (NCDs): A systematic review

Background

The Clinical Frailty Scale (CFS) is a well-established tool that has been widely employed to assess patients' frailty status and to predict clinical outcomes in the acute phase of a disease, but more information is needed to define the implications that this tool have when dealing with Non-Communicable Diseases (NCDs).

Methods

An electronic literature search was performed on PubMed, Scopus, EMBASE, Web of Science, and EBSCO databases to identify studies employing the CFS to assess frailty in patients with NCDs.

Findings

After database searching, article suitability evaluation, and studies' quality assessment, 43 studies were included in the systematic review. Researches were conducted mostly in Japan (37.5%), and half of the studies were focused on cardiovascular diseases (46.42%), followed by cancer (25.00%), and diabetes (10.71%). Simplicity (39.29%), efficacy (37.5%), and rapidity (16.07%) were the CFS characteristics mostly appreciated by the authors of the studies. The CFS-related results indicated that its scores were associated with patients' clinical outcomes (33.92%), with the presence of the disease (12.5%) and, with clinical decision making (10.71%). Furthermore, CFS resulted as a predictor of life expectancy in 23 studies (41.07%), clinical outcomes in 12 studies (21.43%), and hospital admissions/readmissions in 6 studies (10.71%).

Discussion

CFS was found to be a well-established and useful tool to assess frailty in NCDs, too. It resulted to be related to the most important disease-related clinical characteristics and, thus, it should be always considered as an important step in the multidisciplinary evaluation of frail and chronic patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO 2021, ID: CRD42021224214.

Causes, Pattern, Predictors and Prognostic Implications of New Hospitalizations after TAVI: A Long-Term Nationwide Observational Study

Aims

The aim of this study was to investigate the pattern, causes, and predictors of all new hospitalizations in patients who underwent transcatheter aortic valve implantation (TAVI).

Methods and results

The nationwide Swedish TAVI registry was merged with other mandatory healthcare registries, which enabled the analysis of all TAVI procedures, new hospital admissions, and death between the years 2008 and 2017. A total of 2821 patients underwent TAVI with a mean of 2.5 hospitalizations during a mean follow-up of 2.2 years. Hospitalizations were associated with worse prognosis. Heart failure (HF) was the most common cause of hospitalization with 19% having at least one hospitalization due to HF causing, 16% of all-cause admissions, and 50% of cardiovascular admissions. Male gender, age >90 years, high Charlson Comorbidity Index, atrial fibrillation, present neurologic disease, severe renal impairment, peripheral vascular disease, New York Heart Association class IV, mild or moderate mean aortic valve gradients, and pulmonary hypertension were associated with an increased risk for all-cause hospitalizations or death. For cardiovascular hospitalization or death, the pattern was similar, with the addition of impaired systolic left ventricular function as a predictor.

Conclusion

Multiple hospitalizations after TAVI are common and are often caused by HF. Reducing the rate of HF hospitalizations is important to mitigate the burden on the healthcare system due to new hospitalizations after TAVI.

Clinical outcomes in nonagenarians undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis

To compare the risk of procedural complications and mortality after transcatheter aortic valve implantation (TAVI) in nonagenarians (age ≥ 90 years) compared to younger patients (< 90 years). Although TAVI could be considered as a treatment option in nonagenarians, several previous studies have shown conflicting outcomes between nonagenarians and younger patients who underwent TAVI. We conducted a comprehensive literature search through PubMed and EMBASE to investigate the clinical outcomes of nonagenarians after TAVI. The outcomes of interest were short- and long-term mortality and procedural complications. Our study identified 16 observational studies including a total of 179,565 patients (21,674 nonagenarian patients and 157,891 younger patients. Nonagenarians had a significantly higher rate of short- (hazard ratio [HR], 95% confidence interval [CI]: 1.48, 1.38-1.59; P < 0.001) and long-term mortality (HR, 95% CI: 1.34, 1.24-1.44; P < 0.001) than younger patients after TAVI. Furthermore, there were significant differences in major and/or life-threatening bleeding (risk ratio [RR], 95% CI: 1.21, 1.05-1.39; P = 0.008), stroke (HR, 95% CI: 1.24, 1.11-1.40; P < 0.001), and major vascular complication (RR, 95% CI: 2.15, 1.35-3.42; P = 0.001) between nonagenarians and younger patients after TAVI. Minor vascular complication, myocardial infarction and permanent pacemaker implantation rate were similar between the two groups. Nonagenarians had significantly higher rate of short- and long-term mortality, major and/or life-threatening bleeding, stroke, and major vascular complication after TAVI. Although TAVI is a treatment option in nonagenarians, careful and appropriate selection of patients is essential to improve clinical outcomes.