Frailty and pre-frailty in cardiac surgery: a systematic review and meta-analysis of 66,448 patients

Association between preoperative phase angle and all-cause mortality after cardiovascular surgery: A retrospective cohort study

BACKGROUND

The importance of preoperative physical function assessment for post-operative intervention has been reported in older patients undergoing cardiovascular surgery. Phase angle (PhA), measured using bioelectrical impedance analysis, is an indicator of cellular health and integrity and is reported as a prognostic factor in several chronic diseases; however, its association with the long-term prognosis of cardiovascular surgery remains unclear. This study aimed to investigate the prognostic value of PhA for long-term mortality in patients undergoing cardiovascular surgery.

METHODS

This retrospective cohort study included consecutive patients who underwent elective cardiovascular surgery between October 2016 and March 2021 at Nagoya Heart Center, Japan. PhA was assessed using bioelectrical impedance analysis before surgery, and physical function measures (gait speed, grip strength and short physical performance battery [SPPB]) were measured synchronously. The association between PhA and all-cause mortality after discharge was assessed using Kaplan-Meier and multivariate Cox regression analyses. The incremental prognostic value of PhA was compared with other physical function measures using net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

RESULTS

A total of 858 patients were included in the present analysis (mean age = 68.4 ± 11.9 years, 67.6% male). PhA positively correlated with body mass index (ρ = 0.38, P < 0.001), skeletal muscle mass index (ρ = 0.58, P < 0.001), usual gait speed (ρ = 0.44, P < 0.001), grip strength (ρ = 0.73, P < 0.001) and SPPB (ρ = 0.51, P < 0.001). The mean follow-up period, within which 44 (4.7%) died, was 908.9 ± 499.9 days for the entire cohort. Kaplan-Meier survival curves based on the PhA tertiles showed that higher PhA was associated with better survival (log-rank test, P < 0.001). The Cox regression analysis showed the independent association of PhA with mortality risk (hazard ratio: 0.91 per 0.1° increment; 95% confidence interval [CI]: 0.87-0.95; P < 0.001). The NRI and IDI showed significant improvements in predicting mortality after adding PhA to the clinical model consisting of age, sex and cardiac and renal function (NRI: 0.426, 95% CI: 0.124-0.729, P = 0.006; IDI: 0.037, 95% CI: 0.012-0.062, P = 0.003). The predictive model consisting of the clinical model and PhA was superior to the model consisting of the clinical model and each of the other physical function indicators (P < 0.05).

CONCLUSIONS

PhA correlated with physical function and independently predicted long-term mortality after cardiovascular surgery. The additive prognostic value of PhA compared with the other physical function measures suggests the clinical usefulness of preoperative PhA for risk stratification in planning post-operative treatment and rehabilitation.

Chronic Coronary Disease in Older Adults

The number of older adults age ≥75 with chronic coronary disease (CCD) continues to rise. CCD is a major contributor to morbidity, mortality, and disability in older adults. Older adults are underrepresented in randomized controlled trials of CCD, which limits generalizability to older adults living with multiple chronic conditions and geriatric syndromes. This review discusses the presentation of CCD in older adults, reviews the guideline-directed medical and invasive therapies, and recommends a patient-centric approach to making treatment decisions.

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.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Cost-effectiveness of prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO) versus usual care - Protocol for a health economic evaluation alongside a randomized controlled trial

BACKGROUND

Prehabilitation aims to improve patients' functional capacity before surgery to reduce perioperative complications, promote recovery and decrease probability of disability. The planned economic evaluation is performed alongside a large German multi-centre pragmatic, two-arm parallel-group, randomized controlled trial on prehabilitation for frail elderly patients before elective surgery compared to standard care (PRAEP-GO RCT). The aim is to determine the cost-effectiveness and cost-utility of prehabilitation for frail elderly before an elective surgery.

METHODS

The planned health economic evaluation comprises cost-effectiveness, and cost-utility analyses. Analyses are conducted in the German context from different perspectives including the payer perspective, i.e. the statutory health insurance, the societal perspective and the health care provider perspective. Data on outcomes and costs, are collected alongside the ongoing PRAEP-GO RCT. The trial population includes frail or pre-frail patients aged ≥70 years with planned elective surgery. The intervention consists of frailty screening (Fried phenotype), a shared decision-making conference determining modality (physiotherapy and unsupervised physical exercises, nutrition counselling, etc.) and setting (inpatient, day care, outpatient etc.) of a 3-week individual multimodal prehabilitation prior to surgery. The control group receives standard preoperative care. Costs include the intervention costs, the costs of the index hospital stay for surgery, and health care resources consumed during a 12-month follow-up. Clinical effectiveness outcomes included in the economic evaluation are the level of care dependency, the degree of disability as measured by the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), quality-adjusted life years (QALY) derived from the EQ-5D-5L and the German utility set, and complications occurring during the index hospital stay. Each adopted perspective considers different types of costs and outcomes as outlined in the protocol. All analyses will feature Intention-To-Treat analysis. To explore methodological and parametric uncertainties, we will conduct probabilistic and deterministic sensitivity analyses. Subgroup analyses will be performed as secondary analyses.

DISCUSSION

The health economic evaluation will provide insights into the cost-effectiveness of prehabilitation in older frail populations, informing decision-making processes and contributing to the evidence base in this field. Potential limitation includes a highly heterogeneous trial population.

TRIAL REGISTRATION

PRAEP-GO RCT: NCT04418271; economic evaluation: OSF ( https://osf.io/ecm74 ).

Impact of frailty and prefrailty on the mid-term outcomes and rehabilitation course after cardiac surgery

PURPOSE

This study examined the impact of frailty and prefrailty on mid-term outcomes and rehabilitation courses after cardiac surgery.

METHODS

A total of 261 patients (median age: 73 years; 30% female) who underwent elective cardiac surgery were enrolled in this study. The Japanese version of the Cardiovascular Health Study Frailty Index classified 86, 131, and 44 patients into frailty, prefrailty, and robust groups, respectively. We examined the recovery of walking ability, outcomes at discharge, mid-term all-cause mortality, and rehospitalization related to major adverse cardiovascular and cerebrovascular events (MACCE) across the three cohorts.

RESULTS

The 3-year survival rates in the frailty, prefrailty, and robust groups were 87%, 97%, and 100%, respectively (p = 0.003). The free event rates of all-cause mortality and re-hospitalization related to MACCE were 59%, 79%, and 95%, respectively (p < 0.001), with a graded elevation in adjusted morbidity among patients in the prefrailty (hazard ratio [HR], 4.57; 95% confidence interval [CI], 1.08-19.4) and frailty (HR, 9.29; 95% CI 2.21-39.1) groups. Patients with frailty also experienced a delayed recovery of walking ability and a reduced number of patients with frailty were discharged home.

CONCLUSION

Frailty and prefrailty adversely affect the mid-term prognosis and rehabilitation course after cardiac surgery.

Does prehabilitation before esophagectomy improve postoperative outcomes? A systematic review and meta-analysis

Esophagectomy for esophageal cancer is associated with high morbidity. It remains unclear whether prehabilitation, a strategy aimed at optimizing patients' physical and mental functioning prior to surgery, improves postoperative outcomes. A systematic review and meta-analysis was conducted to evaluate the effect of prehabilitation on post-operative outcomes after esophagectomy. Data sources included Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PEDro, with information from 1 January 2000 to 5 August 2023. The analysis included randomized controlled trials and observational studies that compared prehabilitation interventions to standard care prior to esophagectomy. A random effects model was used to generate a pooled estimate for pairwise meta-analysis, meta-analysis of proportions, and meta-analysis of means. A total of 1803 patients were included with 584 in randomized controlled trials (RCTs) and 1219 in observational studies. In the randomized evidence, there were no significant differences between prehabilitation and control in the odds of postoperative pneumonia (15.0 vs. 18.9%, odds ratio (OR) 1.06 [95% confidence interval (CI): 0.66;1.72]) or pulmonary complications (14 vs. 25.6%, OR 0.68 [95% CI: 0.32;1.45]). In the observational data, there was a reduction in both postoperative pneumonia (22.5 vs. 32.9%, OR 0.48 [95% CI: 0.28;0.83]) and pulmonary complications (26.1 vs. 52.3%, OR 0.35 [95% CI: 0.17;0.75]) with prehabilitation. Hospital and intensive care unit length of stay (days), operative mortality, and severe complications (Clavien-Dindo ≥ 3) did not differ between groups in both the randomized data and observational data. Prehabilitation demonstrated reductions in postoperative pneumonia and pulmonary complications in observational studies, but not RCTs. The overall certainty of these findings is limited by the low quality of the available evidence.

Association between frailty and clinical outcomes in patients undergoing craniotomy-systematic review and meta-analysis of observational studies

BACKGROUND

Frailty in patients undergoing craniotomy may affect perioperative outcomes. There have been a number of studies published in this field; however, evidence is yet to be summarized in a quantitative review format. We conducted a systematic review and meta-analysis to examine the effects of frailty on perioperative outcomes in patients undergoing craniotomy surgery.

METHODS

Our eligibility criteria included adult patients undergoing open cranial surgery. We searched MEDLINE via Ovid SP, EMBASE via Ovid SP, Cochrane Library, and grey literature. We included retrospective and prospective observational studies. Our primary outcome was a composite of complications as per the Clavien-Dindo classification system. We utilized a random-effects model of meta-analysis. We conducted three preplanned subgroup analyses: patients undergoing cranial surgery for tumor surgery only, patients undergoing non-tumor surgery, and patients older than 65 undergoing cranial surgery. We explored sources of heterogeneity through a sensitivity analysis and post hoc analysis.

RESULTS

In this review of 63,159 patients, the pooled prevalence of frailty was 46%. The odds ratio of any Clavien-Dindo grade 1-4 complication developing in frail patients compared to non-frail patients was 2.01 [1.90-2.14], with no identifiable heterogeneity and a moderate level of evidence. As per GradePro evidence grading methods, there was low-quality evidence for patients being discharged to a location other than home, length of stay, and increased mortality in frail patients.

CONCLUSION

Increased frailty was associated with increased odds of any Clavien-Dindo 1-4 complication. Frailty measurements may be used as an integral component of risk-assessment strategies to improve the quality and value of neurosurgical care for patients undergoing craniotomy surgery.

ETHICS AND DISSEMINATION

Formal ethical approval is not needed, as primary data were not collected.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO identification number: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=405240.

Frailty efficacy as a predictor of clinical and cognitive complications in patients undergoing coronary artery bypass grafting: a prospective cohort study

BACKGROUND

Frailty is proposed as a predictor of outcomes in patients undergoing major surgeries, although data on the association of frailty and coronary artery bypass grafting (CABG) are lacking. We assessed the association between frailty and cognitive and clinical complications following CABG.

METHODS

This prospective study included patients aged over 60 years undergoing elective CABG at Tehran Heart Center from 2020 to 2022. Baseline and three-month follow-up data on frailty using the Frail scale and clinical Frail scale, functional status using the Lawton Instrumental Activities of Daily Living Scale (IADL), cognitive function by Montreal Cognitive Assessment (MoCA), and depression by the Geriatric Depression Scale (GDS) were obtained. The incidence of adverse outcomes was investigated at the three-month follow-up. Outcomes between frail and non-frail groups were compared utilizing T-tests and Mann-Whitney U tests, as appropriate.

RESULTS

We included 170 patients with a median age of 66 ± 4 years (75.3% male). Of these, 58 cases were classified as frail, and 112 individuals were non-frail, preoperatively. Frail patients demonstrated significantly worse baseline MOCA scores (21.08 vs. 22.41, P = 0.045), GDS (2.00 vs. 1.00, P = 0.009), and Lawton IADL (8.00 vs. 6.00, P < 0.001) compared to non-frail. According to 3-month follow-up data, postoperative MOCA and GDS scores were comparable between the two groups, while Lawton IADL (8.00 vs. 6.00, P < 0.001) was significantly lower in frail cases. A significantly higher rate of readmission (1.8% vs. 12.1%), sepsis (7.1% vs. 19.0%), as well as a higher Euroscore (1.5 vs. 1.9), was observed in the frail group. A mildly significantly more extended ICU stay (6.00 vs. 5.00, p = 0.051) was shown in the frail patient.

CONCLUSION

Frailty showed a significant association with a worse preoperative independence level, cognitive function, and depression status, as well as increased postoperative complications.

Frailty, periinterventional complications and outcome in patients undergoing percutaneous mitral and tricuspid valve repair

BACKGROUND

Frailty is common in elderly and multimorbid patients and associated with increased vulnerability to stressors.

METHODS

In a single centre study frailty according to Fried criteria was assessed in consecutive patients before transcatheter mitral and tricuspid valve repair. Postprocedural infections, blood transfusion and bleeding and renal failure were retrospectively assessed from records. Median follow-up time for survival was 560 days (IQR: 363 to 730 days).

RESULTS

90% of 626 patients underwent mitral valve repair, 5% tricuspid valve repair, and 5% simultaneous mitral and tricuspid valve repair. 47% were classified as frail. Frailty was associated with a significantly increased frequency of bleeding (16 vs 10%; p = 0.016), blood transfusions (9 vs 3%; p =  < 0.001) and infections (18 vs 10%; p = 0.006), but not with acute kidney injury (20 vs 20%; p = 1.00). Bleeding and infections were associated with longer hospital stays, with a more pronounced effect in frail patients (interaction test p < 0.05, additional 3.2 and 4.1 days in frail patients, respectively). Adjustment for the occurrence of complications did not attenuate the increased risk of mortality associated with frailty (HR 2.24 [95% CI 1.62-3.10]; p < 0.001).

CONCLUSIONS

Bleeding complications and infections were more frequent in frail patients undergoing transcatheter mitral and tricuspid valve repair and partly explained the longer hospital stay. Albeit some of the complications were associated with higher long-term mortality, this did not explain the strong association between frailty and mortality. Further research is warranted to explore interventions targeting periprocedural complications to improve outcomes in this vulnerable population.

A Frailty Index to Predict Mortality, Resource Utilization and Costs in Patients Undergoing Coronary Artery Bypass Graft Surgery in Ontario

Background

People living with frailty are vulnerable to poor outcomes and incur higher health care costs after coronary artery bypass graft (CABG) surgery. Frailty-defining instruments for population-level research in the CABG setting have not been established. The objectives of the study were to develop a preoperative frailty index for CABG (pFI-C) surgery using Ontario administrative data; assess pFI-C suitability in predicting clinical and economic outcomes; and compare pFI-C predictive capabilities with other indices.

Methods

A retrospective cohort study was conducted using health administrative data of 50,682 CABG patients. The pFI-C comprised 27 frailty-related health deficits. Associations between index scores and mortality, resource use and health care costs (2022 Canadian dollars [CAD]) were assessed using multivariable regression models. Capabilities of the pFI-C in predicting mortality were evaluated using concordance statistics; goodness of fit of the models was assessed using Akakie Information Criterion.

Results

As assessed by the pFI-C, 22% of the cohort lived with frailty. The pFI-C score was strongly associated with mortality per 10% increase (odds ratio [OR], 3.04; 95% confidence interval [CI], [2.83,3.27]), and was significantly associated with resource utilization and costs. The predictive performances of the pFI-C, Charlson, and Elixhauser indices and Johns Hopkins Aggregated Diagnostic Groups were similar, and mortality models containing the pFI-C had a concordance (C)-statistic of 0.784. Cost models containing the pFI-C showed the best fit.

Conclusions

The pFI-C is predictive of mortality and associated with resource utilization and costs during the year following CABG. This index could aid in identifying a subgroup of high-risk CABG patients who could benefit from targeted perioperative health care interventions.

Sternal resection and reconstruction: a review

Sternal resection and reconstruction is a rare but sometimes challenging procedure due to its profound anatomical and functional implications. For these reasons, an adequate preoperative evaluation is crucial in each patient, especially when we are faced with malignant lesions that sometimes require extensive radical resections, thus demanding an integrated reconstructive strategy that allows stabilizing the chest wall, protecting the underlying mediastinum and minimize resulting deformity. The large number of available reconstruction techniques and the lack of quality studies for their analysis mean that sternal reconstruction depends to a great extent on the consensus of experts or, more frequently, on the simple preference of each surgical team. This article aims to provide an overview of sternal resection and reconstruction. Indications for partial versus total or subtotal sternectomy are suggested and their surgical and oncological outcomes are presented. The use of rigid or semi-rigid prostheses is an ongoing debate, although recent functional data advise reserving rigid reconstructions for extensive defects. Sternectomy for primary tumors or local tumor involvement has a good prognosis with an overall survival of 5 and 10 years: 67% and 58%, respectively, provided that a radical resection with free surgical margins is performed. Breast cancer is the most common secondary sternal tumor, and surgery can offer 5-year overall survival ranging from 20% to 50% provided an R0 resection is achieved, although radical surgery does not appear to decrease rates. of recurrence. Metastases of origin other than the breast give the worst results (less than 40% at 36 months and 0% at 5 years) and although the data available on these cases are limited, the radicality of the resection does not seem to modify the survival or recurrence rates, so a conservative approach is probably more appropriate.

Cardiogeriatrics: the current state of the art

It is estimated that by 2050, 17% of the world's population will be greater than 85 years old, which, combined with cardiovascular disease (CVD) being the leading cause of death and disability, sets an unprecedented burden on our health and care systems. This perfect storm will be accompanied by a rise in the prevalence of CVD due to increased survival of patients with pre-existing CVD and the incidence of CVD that is associated with the process of ageing. In this review, we will focus on the diagnosis and management of common CVD conditions in old age, namely: heart failure (HF), coronary artery disease (CAD), atrial fibrillation (AF) and valvular heart disease (VHD). Despite limited evidence, clinical guidelines are increasingly considering the complexity of management of these conditions in the older person, which often coexist, for example, AF and HF or CAD and VHD. Furthermore, they, in turn, need specific consideration in the context of comorbidities, polypharmacy, frailty and impaired cognition found in this age group. Hence, the emerging role of the geriatric cardiologist is therefore vital in performing comprehensive geriatric assessment, attending multidisciplinary team meetings and ultimately considering the patient and the sum of their diseases in their totality. There have been recent advances in CVD management but how we apply these to deliver integrated care to the elderly population is key. This review article aims to bring together emerging studies and guidelines on assessment and management of CVD in the elderly, summarising latest definitions, diagnostics, therapeutics and future challenges.

Impact of Frailty in Patients Undergoing Minimally Invasive Mitral Valve Surgery

OBJECTIVE

Psoas muscle size is a reliable marker of sarcopenia and frailty that correlates with adverse outcomes after cardiac surgery. However, its use in mitral and minimally invasive cardiac surgery is lacking. We sought to determine whether frailty, as measured by psoas muscle index, increases surgical risk for minimally invasive mitral valve surgery.

METHODS

Patients undergoing isolated minimally invasive mitral surgery via right minithoracotomy were identified. Patients who underwent maze, tricuspid intervention, and those who were emergent were excluded. Total psoas muscle area was calculated using the average cross-sectional area at the L3 vertebra on computed tomography scan and indexed to body surface area. Sarcopenia was defined as <25th gender-specific percentile. Patients were stratified by sarcopenia status and outcomes compared.

RESULTS

Of 287 total patients, 192 patients met inclusion criteria. Sarcopenic patients were 6 years older (66 vs 60 years, P = 0.01), had lower preoperative albumin levels (4.0 vs 4.3 g/dL, P < 0.001), and had higher Society of Thoracic Surgeons risk of morbidity/mortality (13.1% vs 9.0%, P = 0.003). Operative major morbidity or mortality was 6.4% versus 5.5% (P = 0.824), while the 1-year mortality rate was 2.1% versus 0% (P = 0.08). After risk adjustment, psoas index did not predict operative morbidity or mortality. However, sarcopenia was associated with higher odds of readmission (odds ratio = 0.74, P = 0.02).

CONCLUSIONS

Contrary to other cardiac operations, for patients undergoing isolated minimally invasive mitral valve surgery, sarcopenia was not associated with increased perioperative risk except for higher readmission rates. Minimally invasive surgical approaches should be strongly considered as the approach of choice in frail patients.

The frail patient undergoing cardiac surgery: lessons learned and future perspectives

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.

Racial differences in phenotypic frailty assessment among general thoracic surgery patients

Objectives

The American Association for Thoracic Surgery recommends using frailty assessments to identify patients at higher risk of perioperative morbidity and mortality. We evaluated what patient factors are associated with frailty in a thoracic surgery patient population.

Methods

New patients aged more than 50 years who were evaluated in a thoracic surgery clinic underwent routine frailty screening with a modified Fried's Frailty Phenotype. Differences in demographics and comorbid conditions among frailty status groups were assessed with chi-square and Student t tests. Logistic regressions performed with binomial distribution assessed the association of demographic and clinical characteristics with nonfrail, frail, prefrail, and any frailty (prefrail/frail) status.

Results

The study population included 317 patients screened over 19 months. Of patients screened, 198 (62.5%) were frail or prefrail. Frail patients undergoing thoracic surgery were older, were more likely single or never married, had lower median income, and had lower percent predicted diffusion capacity of the lungs for carbon monoxide and forced expiratory volume during 1 second (all P < .05). More non-Hispanic Black patients were frail and prefrail compared with non-Hispanic White patients (P = .003) and were more likely to score at least 1 point on Fried's Frailty Phenotype (adjusted odds ratio, 3.77; P = .02) when controlling for age, sex, number of comorbidities, median income, diffusion capacity of the lungs for carbon monoxide, and forced expiratory volume during 1 second. Non-Hispanic Black patients were more likely than non-Hispanic White patients to score points for slow gait and low activity (both P < .05).

Conclusions

Non-Hispanic Black patients undergoing thoracic surgery are more likely to score as frail or prefrail than non-Hispanic White patients. This disparity stems from differences in activity and gait speed. Frailty tools should be examined for factors contributing to this disparity, including bias.

Con: Can We Influence Postoperative Outcomes of Frail Patients After Cardiac Surgery?

Frail patients are scheduled routinely for elective cardiovascular surgery. Despite the proven association between frailty and postoperative outcomes, currently, there is no consistent evidence that the preoperative optimization of frail patients with preoperative nutrition support and exercise programs can alter postoperative mortality. Established frailty diagnostic tools are not sufficient to grasp the multidimensional nature of frailty in cardiovascular patients. Prehabilitation programs and preoperative nutritional support are time- and resource-consuming and, therefore, are hard to implement in routine clinical practice.

Impact of frailty on the outcomes of patients undergoing degenerative spine surgery: a systematic review and meta-analysis

BACKGROUND

Degenerative spinal diseases are common in older adults with concurrent frailty. Preoperative frailty is a strong predictor of adverse clinical outcomes after surgery. This study aimed to investigate the association between health-related outcomes and frailty in patients undergoing spine surgery for degenerative spine diseases.

METHODS

A systematic review and meta-analysis were performed by electronically searching Ovid-MEDLINE, Ovid-Embase, Cochrane Library, and CINAHL for eligible studies until July 16, 2022. We reviewed all studies, excluding spinal tumours, non-surgical procedures, and experimental studies that examined the association between preoperative frailty and related outcomes after spine surgery. A total of 1,075 articles were identified in the initial search and were reviewed by two reviewers, independently. Data were subjected to qualitative and quantitative syntheses by meta-analytic methods.

RESULTS

Thirty-eight articles on 474,651 patients who underwent degenerative spine surgeries were included and 17 papers were quantitatively synthesized. The health-related outcomes were divided into clinical outcomes and patient-reported outcomes; clinical outcomes were further divided into postoperative complications and supportive management procedures. Compared to the non-frail group, the frail group was significantly associated with a greater risk of high mortality, major complications, acute renal failure, myocardial infarction, non-home discharge, reintubation, and longer length of hospital stay. Regarding patient-reported outcomes, changes in scores between the preoperative and postoperative Oswestry Disability Index scores were not associated with preoperative frailty.

CONCLUSIONS

In degenerative spinal diseases, frailty is a strong predictor of adverse clinical outcomes after spine surgery. The relationship between preoperative frailty and patient-reported outcomes is still inconclusive. Further research is needed to consolidate the evidence from patient-reported outcomes.

Feasibility of frailty screening among patients with advanced heart failure

BACKGROUND

Frailty is common among patients with advanced heart failure (HF), and screening for frailty to guide care is recommended. Although multiple tools are available to screen for frailty, the feasibility of routinely incorporating frailty screening into daily clinical practice among hospitalised advanced HF patients has not been rigorously tested.

METHODS

This was a prospective, single-centre, quality improvement study. Two brief frailty screening tools were incorporated into palliative care consultations for all patients ≥50 years from August 2021 to October 2022. In the first phase, the Clinical Frailty Scale (CFS) was implemented, followed by the Study of Osteoporotic Fracture (SOF) tool or a modified SOF (mSOF) version in the second phase. The primary outcome was feasibility (%) of performing frailty screenings for this high-risk population.

RESULTS

A total of 212 patients (mean age 69±10 years, 69% male, 79% white, 30% with ischaemic HF) were referred for palliative care consultation during the study period. Overall, frailty screens were completed in 86% (n=183) of patients. CFS and mSOF reached >80% of adoption, while SOF adoption was 54%. Altogether, 52% of the population screened frail by use of CFS and 52% also by mSOF. All clinicians (n=6) participating in the study reported that frailty screening tools were useful and acceptable, and 83% reported plans for continued utilisation in future clinical practice.

CONCLUSIONS

Frailty screening with CFS or mSOF tools was feasible in hospitalised patients with advanced HF. Tools that require physical assessment were more challenging to implement. These data support the feasibility of incorporating questionnaire-based frailty screening in a busy hospital setting.

Preoperative frailty and adverse outcomes following coronary artery bypass grafting surgery in US veterans

BACKGROUND

Contemporary guidelines emphasize the value of incorporating frailty into clinical decision-making regarding revascularization strategies for coronary artery disease. Yet, there are limited data describing the association between frailty and longer-term mortality among coronary artery bypass grafting (CABG) patients.

METHODS

We conducted a retrospective cohort study (2016-2020, 40 VA medical centers) of US veterans nationwide that underwent coronary artery bypass grafting (CABG). Frailty was quantified by the Veterans Administration Frailty Index (VA-FI), which applies the cumulative deficit method to render a proportion of 30 pertinent diagnosis codes. Patients were classified as non-frail (VA-FI ≤ 0.1), pre-frail (0.1 < VA-FI ≤ 0.2), or frail (VA-FI > 0.2). We used Cox proportional hazards models to ascertain the association of frailty with all-cause mortality. Our primary study outcome was 5-year all-cause mortality; the co-primary outcome was days alive and out of the hospital within the first postoperative year.

RESULTS

There were 13,554 CABG patients (median 69 years, 79% White, 1.5% women). The mean pre-operative VA-FI was 0.21 (SD: 0.11); 31% were pre-frail (VA-FI: 0.17) and 47% were frail (VA-FI: 0.31). Frail patients were older and had higher co-morbidity burdens than pre-frail and non-frail patients. Compared with non-frail patients (13.0% [11.4, 14.7]), there was a significant association between frail and pre-frail patients and increased cumulative 5-year all-cause mortality (frail: 24.8% [23.3, 26.1]; HR: 1.75 [95% CI 1.54, 2.00]; pre-frail 16.8% [95% CI 15.3, 18.4]; HR 1.2 [1.08,1.34]). Compared with non-frail patients (mean 362[SD 12]), pre-frail (mean 361 [SD 14]; p < 0.01) and frail patients (mean 358[SD 18]; p < 0.01) spent fewer days alive and out of the hospital in the first postoperative year.

CONCLUSIONS

Pre-frailty and frailty were prevalent among US veterans undergoing CABG and associated with worse mid-term outcomes. Given the high prevalence of frailty with attendant adverse outcomes, there may be an opportunity to improve outcomes by identifying and mitigating frailty before surgery.

Mechanical Circulatory Support Therapy in the Cardiac Intensive Care Unit

Mechanical circulatory support (MCS) includes temporary and durable mechanical devices used for two sets of indications: 1. acute heart failure (HF) secondary sepsis, a myocardial infarction, or pulmonary emboli, and 2. for chronic end-stage HF secondary to worsening cardiomyopathy despite guideline driven medical treatment. This article is to aide cardiac intensive care unit (ICU) nurses in understanding the history of MCS therapy, the care of the MCS patient in the cardiac ICU, the critical and collaborative role of transplant teams with MCS therapy, educational needs for a successful discharge, and implications for education and shared decision-making when placing these devices.

Frailty in the Advanced Heart Failure Patient: A Challenging, Neglected, Yet Potentially Modifiable Risk Factor

Purpose of review

There is an increasing push for frailty assessment to become a routine part of the evaluation of potential candidates for advanced heart failure (AHF) therapies. The aim of this review is to highlight the importance of frailty in the care of the AHF patient.

Recent findings

This review focuses on some of the available data for the assessment of frailty specifically in the AHF, durable mechanical circulatory support (MCS), and heart transplant (HT) patients, and explores some of the challenges in assessing frailty in these patient populations.

Summary

As the presence of frailty can significantly impact outcomes after HT and durable MCS implantation, there should be an increased recognition of this entity during routine evaluation and management of the AHF patient.

One-Year Survival after Cardiac Surgery in Frail Older People-Social Support Matters: A Prospective Cohort Study

There are increasing rates of cardiac surgery in the elderly. Frailty, depression, and social vulnerability are frequently present in older people, and should be considered while assessing risk and providing treatment options. We aimed to analyse the impact of clinically relevant variables on survival at one year, and identify areas of future intervention. We performed a prospective cohort study at a University Hospital, with a sample of 309 elective cardiac surgery patients 65 years old and over. Their socio-demographic and clinical variables were collected. Frailty prevalence was 61.3%, while depression was absent in the majority of patients. Mortality was 1.6% and 7.8% at 30 days and 12 months, respectively. After Kaplan-Meier analysis, severe frailty (p = 0.003), severe depression (p = 0.027), pneumonia until 30 days (p = 0.014), and re-operation until 12 months (p = 0.003) significantly reduced survival, while social support increased survival (p = 0.004). In the adjusted multivariable Cox regression model, EuroSCORE II (HR = 1.27 [95% CI 1.069-1.499] p = 0.006), pneumonia until 30 days (HR = 4.19 [95% CI 1.169-15.034] p = 0.028), re-intervention until 12 months (HR = 3.14 [95% CI 1.091-9.056] p = 0.034), and social support (HR = 0.24 [95% CI 0.079-0.727] p = 0.012) explained time until death. Regular screening for social support, depression, and frailty adds relevant information regarding risk stratification, perioperative interventions, and decision-making in older people considered for cardiac surgery.

Assessment and Management of Older Adults Undergoing PCI, Part 1: A JACC: Advances Expert Panel

As the population ages, older adults represent an increasing proportion of patients referred to the cardiac catheterization laboratory. Older adults are the highest-risk group for morbidity and mortality, particularly after complex, high-risk percutaneous coronary interventions. Structured risk assessment plays a key role in differentiating patients who are likely to derive net benefit vs those who have disproportionate risks for harm. Conventional risk assessment tools from national cardiovascular societies typically rely on 3 pillars: 1) cardiovascular risk; 2) physiologic and hemodynamic risk; and 3) anatomic and procedural risks. We propose adding a fourth pillar: geriatric syndromes, as geriatric domains can supersede all other aspects of risk.

Exploring the Frailty Components Related to Hospitalization-Associated Disability in Older Patients After Cardiac Surgery Using a Comprehensive Frailty Assessment

BACKGROUND

We investigated the components of frailty associated with hospitalization-associated disability (HAD) after cardiac surgery.Methods and Results: This retrospective, observational study evaluated 1,446 older patients after elective cardiac surgery at the Sakakibara Heart Institute. We examined the association between HAD and 7 domains of frailty assessed by the Kihon Checklist. HAD was defined as a decline in the ability to perform activities of daily living (ADL) between admission and discharge, as assessed by the Barthel Index. Logistic regression and decision tree analysis were used to identify associations between the number and type of frailty components and HAD. Of the 1,446 patients, 190 were excluded, and 90 (7%) developed HAD. An increase in the number of frailty components was a risk factor for HAD (odds ratio: 1.88, 95% confidence interval: 1.62-2.17). Decision tree analysis identified physical functional decline, depression, and cognitive dysfunction as factors associated with HAD. The incidence of HAD was highest in cases of physical functional decline (21%) and lowest for cases in which the 3 aforementioned factors were absent (2.8%).

CONCLUSIONS

An increased number of frailty factors increased the risk of HAD and the findings also reaffirmed the importance of a comprehensive assessment to evaluate the risk of HAD, including evaluation of physical function, cognitive function, and depression.

How Can We Best Measure Frailty in Cardiosurgical Patients?

BACKGROUND

Frailty is gaining importance in cardiothoracic surgery and is a risk factor for adverse outcomes and mortality. Various frailty scores have since been developed, but there is no consensus which to use for cardiac surgery.

METHODS

In an all-comer prospective study of patients presenting for cardiac surgery, we assessed frailty and analyzed complication rates in hospital and 1-year mortality, as well as laboratory markers before and after surgery.

RESULTS

246 included patients were analyzed. A total of 16 patients (6.5%) were frail, and 130 patients (52.85%) were pre-frail, summarized in the frail group (FRAIL) and compared to the non-frail patients (NON-FRAIL). The mean age was 66.5 ± 9.05 years, 21.14% female. The in-hospital mortality rate was 4.88% and the 1-year mortality rate was 6.1%. FRAIL patients stayed longer in hospital (FRAIL 15.53 ± 8.5 days vs. NON-FRAIL 13.71 ± 8.94 days, p = 0.004) and in intensive/intermediate care units (ITS/IMC) (FRAIL 5.4 ± 4.33 days vs. NON-FRAIL 4.86 ± 4.78 days, p = 0.014). The 6 min walk (6 MW) (317.92 ± 94.17 m vs. 387.08 ± 93.43 m, p = 0.006), mini mental status (MMS) (25.72 ± 4.36 vs. 27.71 ± 1.9, p = 0.048) and clinical frail scale (3.65 ± 1.32 vs. 2.82 ± 0.86, p = 0.005) scores differed between patients who died within the first year after surgery compared to those who survived this period. In-hospital stay correlated with timed up-and-go (TUG) (TAU: 0.094, p = 0.037), Barthel index (TAU-0.114, p = 0.032), hand grip strength (TAU-0.173, p < 0.001), and EuroSCORE II (TAU 0.119, p = 0.008). ICU/IMC stay duration correlated with TUG (TAU 0.186, p < 0.001), 6 MW (TAU-0.149, p = 0.002), and hand grip strength (TAU-0.22, p < 0.001). FRAIL patients had post-operatively altered levels of plasma-redox-biomarkers and fat-soluble micronutrients.

CONCLUSIONS

frailty parameters with the highest predictive value as well as ease of use could be added to the EuroSCORE.

Minimally invasive direct coronary artery bypass and percutaneous coronary intervention followed by transcatheter aortic valve implantation: A promising concept in high-risk octogenarians

Objectives

In this article, we present our initial clinical experience with staged minimally invasive direct coronary bypass (MIDCAB), percutaneous coronary intervention (PCI), and transcatheter aortic valve implantation (TAVI) in high-risk octogenarians (Hybrid).

Background

The use of percutaneous techniques for managing structural heart diseases, especially in elderly high-risk patients, has revolutionized the treatment of structural heart diseases. These procedures are present predominantly being offered as isolated interventions. The feasibility, clinical benefit, and outcomes of combining these techniques with MIDCAB have not been sufficiently explored and have subsequently been underreported in the contemporary literature.

Methods

Four consecutive octogenarians with severe aortic stenosis (AS) and complex coronary artery disease (CAD) that were at high risk for conventional surgery with extracorporeal circulation (ECC) were discussed in our Multidisciplinary Heart Team (MDH). Our MDH consisted of an interventional cardiologist, cardiac surgeon, and cardiac anesthesiologist. A hybrid approach with the alternative strategy comprising of MIDCAB, PCI, and TAVI in a staged fashion was agreed on. All 4 patients had both PCI/stenting and MIDCAB prior to deployment of the TAVI-prosthesis.

Results

From January 2019 to December 2020, 4 consecutive patients aged between 83 and 85 (3 male/1 female) years were scheduled for MIDCAB/PCI followed by percutaneous treatment of severe symptomatic AS. Intraoperatively, one patient was converted to full sternotomy, and surgery was performed by off-pump coronary artery bypass grafting. The overall procedural success rate was 100% in all 4 patients with resolution of their initial presenting cardiopulmonary symptoms. There were no severe complications associated with all hybrid procedures. There was no 30-day mortality in all patients. All patients were discharged home with a median hospital stay ranging between 9 and 25 days. All patients have since then been followed-up regularly. There was one noncardiac-related mortality at 6-months postsurgery. All other patients were well at 1-year follow-up with improved New York Heart Association Class II.

Conclusions

In a selected group of elderly, high prohibitive risk patients with CAD and severe symptomatic AS, a staged approach with MIDCAB and PCI followed by TAVI can be safely performed with excellent outcomes. We advocate a MDH-based preliminary evaluation of this patient cohort in selecting suitable patients and appropriate timing of each stage of the hybrid procedure.

The prognostic impacts of frailty on clinical and patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and meta-analysis

BACKGROUND

Frailty is emerging as an important prognostic indicator for patients undergoing cardiac surgeries/procedures. We sought to evaluate the prognostic and differential impacts of frailty on patients undergoing coronary artery or valvular surgical procedures of different levels of invasiveness, and to explore the differential predictability of various frailty measurement models.

METHODS

Eight databases were searched for prospective cohort studies that have adopted validated measure(s) of frailty and reported clinical, healthcare service utilization, or patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures.

RESULTS

Sixty-two articles were included (N = 16,679). Frailty significantly predicted mortality (short-term [≤ 30 days]: odds ratio [OR]: 2.33, 95% confidence interval [CI]: 1.28-4.26; midterm [6 months to 1 year]: OR: 3.93, 95%CI: 2.65-5.83; long-term [>1 year]: HR: 2.23, 95%CI: 1.60-3.11), postoperative complications (ORs: 2.54-3.57), discharge to care facilities (OR: 5.52, 95%CI: 3.84-7.94), hospital readmission (OR: 2.00, 95%CI: 1.15-3.50), and reduced health-related quality of life (HRQoL; standardized mean difference: -0.74, 95%CI: -1.30 to -0.18). Subgroup analyses showed that frailty exerted a greater impact on short-term mortality in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional and physical-aspect-focused frailty measurements performed equally in predicting mortality, but multidimensional measurements were more predictive of hospital readmission than physical-aspect-focused measurements.

CONCLUSION

Frailty was predictive of postoperative mortality, complications, increased healthcare service utilization, and reduced HRQoL. The impact of frailty on short-term mortality was more prominent in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional measures of frailty enhanced prognostic risk estimation, especially for hospital readmission.

Association between hospital-acquired functional decline and 2-year readmission or mortality after cardiac surgery in older patients: a multicenter, prospective cohort study

BACKGROUND

Hospital-acquired functional decline (HAFD) is a new predictor of poor prognosis in hospitalized older patients.

AIMS

We aimed to assess the impact of HAFD on the prognosis of older cardiac surgical patients 2 years after discharge.

METHODS

This multicenter prospective cohort study assessed 293 patients with cardiac disease aged ≥ 65 years who underwent cardiac surgery at 7 Japanese hospitals between June 2017 and June 2018. The primary endpoint was the composite outcome of cardiovascular-related readmission and all-cause mortality 2 years after discharge. HAFD was assessed using the total Short Physical Performance Battery at hospital discharge.

RESULTS

The primary outcome was observed in 17.3% of the 254 included patients, and HAFD was significantly associated with the primary outcome. Female sex (hazard ratio [HR], 2.451; 95% confidence interval [CI] 1.232-4.878; P = 0.011), hemoglobin level (HR, 0.839; 95% CI 0.705-0.997; P = 0.046), preoperative frailty (HR, 2.391; 95% CI 1.029-5.556; P = 0.043), and HAFD (HR, 2.589; 95% CI 1.122-5.976; P = 0.026) were independently associated with the primary outcome. The incidence rate of HAFD was 22%, with female sex (odds ratio [OR], 1.912; 95% CI 1.049-3.485; P = 0.034), chronic obstructive pulmonary disease (OR, 3.958; 95% CI 1.413-11.086; P = 0.009), and the time interval (days) between surgery and the start of ambulation (OR, 1.260, 95% CI 1.057-1.502; P = 0.010) identified as significant factors.

DISCUSSION

HAFD was found to be an independent prognostic determinant of the primary outcome 2 years after discharge.

CONCLUSION

HAFD prevention should be prioritized in the hospital care of older cardiac surgery patients.

A Remote Diet and Exercise Intervention for Surgical Patients With Prefrailty and Frailty During the COVID-19 Pandemic

Objectives: To facilitate the success of surgical patients with prefrailty and frailty in meeting diet and exercise goals in the context of the COVID-19 pandemic, and to encourage patient satisfaction with remote care. Methods: In the setting of the COVID-19 pandemic, surgical patients with prefrailty and frailty were offered remote visits with a geriatrician and a remote diet and exercise coaching program. Results: The coaching participants set a mean of 37 (±15) individualized dietary goals and 17 (±11) individualized exercise goals. 75% of the coaching participants met at least 65% of their dietary goals and 75% met at least 50% of their exercise goals. All patients met at least one diet goal and at least one exercise goal. Patients endorsed high levels of satisfaction with the program. Discussion: Diet and exercise interventions for surgical patients with prefrailty and frailty have potential for adaptation to remote formats. Such interventions may facilitate patients' meeting of individualized diet and exercise goals and may also encourage patient satisfaction.

Frailty as a predictor of adverse outcomes in head and neck reconstruction: A systematic review

BACKGROUND

Frailty has been shown to adversely impact outcomes in a number of surgical disciplines. In head and neck reconstructive surgery, frailty may represent a significant risk factor in predicting post-operative outcomes due to the common characteristics of the patient population undergoing these procedures.

OBJECTIVES

To summarize the available evidence about frailty as a predictor of post-operative complications, length of hospital stay and quality of life in patients undergoing head and neck reconstructive surgery.

STUDY DESIGN

Systematic Review.

METHODS

The study protocol was registered with PROSPERO, registration CRD42022302899. Methodology was in keeping with the PRISMA Guidelines for Systematic Reviews. MEDLINE, SCOPUS, EMBASE, Web of Science and CENTRAL were the databases searched. Qualitative synthesis of the included studies was carried out, and quality assessment was performed.

RESULTS

Nine studies that reported data on 10,457 patients undergoing reconstruction of the head and neck were included in the review. A number of different tools were used to assess frailty, with the modified frailty index being the most frequently used. In total, 8 studies reported increased rates of complications in patients with increased levels of frailty, irrespective of the frailty tool used, with varied levels of statistical significance across the studies.

CONCLUSION

An association is observed between increased rates of perioperative complications and increased levels of frailty in patients undergoing head and neck reconstruction. Frailty tools may represent a useful method to risk stratify patients undergoing reconstructive head and neck surgery.

[Cognitive impairment in patients of cardiac surgery with senile asthenia syndrome and preastenia]

OBJECTIVE

To identify the features of the cognitive status in patients with cardiac surgery profile with senile asthenia syndrome (SAS) and preasthenia.

MATERIAL AND METHODS

A study included 272 patients admitted for coronary artery bypass grafting (CABG). Screening for preasthenia and SAS in patients before surgery was performed using the Brief Battery of Physical Functioning Tests. SAS and preasthenia were detected in 15% of patients (n=41). Seventy-five patients were selected in the comparison group without asthenia. Assessment of the state of cognitive functions was carried out using screening neuropsychological scales - the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA).

RESULTS

The median of the MMSE score (27 [26; 28] and 28 [27; 29], p=0.04), and the MoCA score (23 [19; 25] and 25 [23; 27], p=0.0085) was significantly lower in patients with asthenia and pre-asthenia compared to patients without asthenia. According to the MoCA, about 60% of patients in the pre-asthenia-asthenia group had severe cognitive impairment, while in the group without asthenia, more than 30% of cases had normal cognitive functions (p=0.003). Significant intergroup differences were found in MoCA subtests, reflecting visuospatial skills, abstraction, verbal fluency and working memory (p=0.01-0.04). Regression analysis showed that age and physical functioning index (severity of asthenia) most significantly contributed to the basic cognitive status assessed by MoCA.

CONCLUSION

Features of the cognitive status in patients of cardiac surgery with the SAS and preasthenia are impairments of visuospatial thinking, verbal fluency, abstract thinking and working memory. The MoCA was shown to be informative in determining the basic cognitive status of cardiac surgical patients. At the same time, the greatest contribution to the basic cognitive status is made by age and the indicator of physical functioning, which characterizes the degree of asthenia.

Diagnosis and Management of Aortic Valvular Disease in the Elderly

Aortic valvular disease, including aortic stenosis and aortic regurgitation, is increasingly common with age. Due to the aging population, more elderly patients are presenting with aortic valve pathology and expectations for prompt diagnosis and efficacious treatment. The current paradigm for aortic valve disease is based on surgical or interventional therapy. In this review, we discuss the approach to diagnosing aortic valvular disease and the different options for treatment based on the most recent evidence.

Comparison of Multidimensional Frailty Instruments for Estimation of Long-term Patient-Centered Outcomes After Cardiac Surgery

Importance

Little is known about the performance of available frailty instruments in estimating patient-relevant outcomes after cardiac surgery.

Objective

To examine how well the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator, the Hospital Frailty Risk Score (HFRS), and the Preoperative Frailty Index (PFI) estimate long-term patient-centered outcomes after cardiac surgery.

Design, Setting, and Participants

This retrospective cohort study was conducted in Ontario, Canada, among residents 18 years and older who underwent coronary artery bypass grafting or aortic, mitral or tricuspid valve, or thoracic aorta surgery between October 2008 and March 2017. Long-term care residents, those with discordant surgical encounters, and those receiving dialysis or dependent on a ventilator within 90 days were excluded. Statistical analysis was conducted from July 2021 to January 2022.

Main Outcomes and Measures

The primary outcome was patient-defined adverse cardiovascular and noncardiovascular events (PACE), defined as the composite of severe stroke, heart failure, long-term care admission, new-onset dialysis, and ventilator dependence. Secondary outcomes included mortality and individual PACE events. The association between frailty and PACE was examined using cause-specific hazard models with death as a competing risk, and the association between frailty and death was examined using Cox models. Areas under the receiver operating characteristic curve (AUROC) were determined over 10 years of follow-up for each frailty instrument.

Results

Of 88 456 patients (22 924 [25.9%] female; mean [SD] age, 66.3 [11.1] years), 14 935 (16.9%) were frail according to ACG criteria, 63 095 (71.3%) according to HFRS, and 76 754 (86.8%) according to PFI. Patients with frailty were more likely to be older, female, and rural residents; to have lower income and multimorbidity; and to undergo urgent surgery. Patients meeting ACG criteria (hazard ratio [HR], 1.66; 95% CI, 1.60-1.71) and those with higher HFRS scores (HR per 1.0-point increment, 1.10; 95% CI, 1.09-1.10) and PFI scores (HR per 0.1-point increment, 1.75; 95% CI, 1.73-1.78) had higher rates of PACE. Similar magnitudes of association were observed for each frailty instrument with death and individual PACE components. The HFRS had the highest AUROC for estimating PACE during the first 2 years and death during the first 4 years, after which the PFI had the highest AUROC.

Conclusions and Relevance

These findings could help to tailor the use of frailty instruments by outcome and follow-up duration, thus optimizing preoperative risk stratification, patient-centered decision-making, candidate selection for prehabilitation, and personalized monitoring and health resource planning in patients undergoing cardiac surgery.

"Age is just a number"; frailty as a marker of peri-operative risk in head and neck surgery: Systematic review and meta-analysis

BACKGROUND

Frailty refers to a patient's reduced capacity to withstand stressors due to a reduction in physiologic reserves. We assessed the impact of frailty on outcomes following head and neck surgery.

METHODS

We performed a systematic review in accordance with the PRISMA guidelines. Meta-analysis was performed using the Mantel-Haenszel method.

RESULTS

Fourteen studies incorporating 182 059 patients were included in qualitative synthesis with 15 953 (8.8%) of patients deemed as frail. Meta-analysis incorporating nine studies demonstrated that frailty is associated with an increased 30 day postoperative morbidity (OR 2.74; 95% CI 1.98-3.80; p < 0.01) and meta-analysis with six studies suggested increased 30-day mortality (OR 2.94; 95% CI 2.62-3.31; p < 0.01). Preliminary meta-analyses between two and five studies suggested that frail patients had reduced overall survival and were more likely to be discharged to a nonhome location or readmitted within 30 days.

CONCLUSIONS

Frailty appears to be associated with poor short-term outcomes following head and neck surgery and may improve understanding of an individual patient's peri-operative risk.

Frailty Syndrome in Older Adults with Cardiovascular Diseases-What Do We Know and What Requires Further Research?

Cardiovascular diseases (CVD) affect 60% of people over 60 years of age and are one of the main causes of death in the world. Diagnosed cardiovascular disease also triples the likelihood of Frailty syndrome (FS). FS has become increasingly relevant in cardiology and cardiac surgery and occurs in a significant number of patients with CVD, with prevalence ranging from 25% to 62%. Viewed in a multidimensional, biopsychosocial perspective, FS increases a patient's vulnerability, making them susceptible to several adverse clinical outcomes. Frailty syndrome also is a predictor of mortality in patients with CVD regardless of age, severity of disease, multi-morbidity, and disability. Frailty syndrome potentially can be prevented in patients with CVD and its early identification is important to avoid the development of disability, dependence on others and reduced quality of life. The aim of this paper is to show the relationship between FS and specific CVDs (coronary artery disease, hypertension, atrial fibrillation, heart failure) and cardiac procedures (device implantation, cardiac surgery, and transcatheter aortic valve implantation). Furthermore, we highlight those areas that require further research to fully understand the relationship between FS and CVD and to be able to minimize or prevent its adverse effects.

Slow gait speed is associated with worse postoperative outcomes in cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Frailty is associated with poorer outcomes in cardiac surgery, but the heterogeneity in frailty assessment tools makes it difficult to ascertain its true impact in cardiac surgery. Slow gait speed is a simple, validated, and reliable marker of frailty. We performed a systematic review and meta-analysis to examine the effect of slow gait speed on postoperative cardiac surgical patients.

METHODS

PubMED, MEDLINE, and EMBASE databases were searched from January 2000 to August 2021 for studies comparing slow gait speed and "normal" gait speed. Primary outcome was in-hospital mortality. Secondary outcomes were composite mortality and major morbidity, AKI, stroke, deep sternal wound infection, prolonged ventilation, discharge to a healthcare facility, and ICU length of stay.

RESULTS

There were seven eligible studies with 36,697 patients. Slow gait speed was associated with increased likelihood of in-hospital mortality (risk ratio [RR]: 2.32; 95% confidence interval [CI]: 1.87-2.87). Additionally, they were more likely to suffer from composite mortality and major morbidity (RR: 1.52; 95% CI: 1.38-1.66), AKI (RR: 2.81; 95% CI: 1.44-5.49), deep sternal wound infection (RR: 1.77; 95% CI: 1.59-1.98), prolonged ventilation >24 h (RR: 1.97; 95% CI: 1.48-2.63), reoperation (RR: 1.38; 95% CI: 1.05-1.82), institutional discharge (RR: 2.08; 95% CI: 1.61-2.69), and longer ICU length of stay (MD: 21.69; 95% CI: 17.32-26.05).

CONCLUSION

Slow gait speed is associated with poorer outcomes in cardiac surgery. Frail patients are twofold more likely to die during hospital admission than nonfrail counterparts and are at an increased risk of developing various perioperative complications.