Impact of Frailty Markers for Unplanned Hospital Readmission Following Transcatheter Aortic Valve Implantation

The Impact of Frailty and Surgical Risk on Health-Related Quality of Life After TAVI

Symptomatic aortic stenosis and frailty reduce health-related quality of life (HrQoL). Transcatheter aortic valve implantation (TAVI) in patients at high to extreme risk has been proven to have a beneficial effect on HrQoL. Currently, TAVI is also considered in patients at intermediate risk. Our meta-analysis investigates whether benefits to HrQoL after TAVI is more pronounced in frail patients and patients at high to extreme vs. intermediate surgical risk. A systematic search of the literature was performed in November 2021 and updated in November 2023 in PUBMED, EMBASE, and the Cochrane Controlled Trials Register. Statistical analysis was performed according to the inverse variance method and the random effects model. A total of 951 studies were assessed, of which 19 studies were included. Meta-analysis showed a mean increase in the Kansas City Cardiomyopathy Questionnaire (KCCQ) score of 29.6 points (6.0, 33.1) in high to extreme risk patients versus 21.0 (20.9, 21.1) in intermediate risk patients (p < 0.00001) and 24.6 points (21.5, 27.8) in frail patients versus 26.8 (20.2, 33.4) in the general TAVI population (p = 0.55). However, qualitative analyses of non-randomized studies showed the opposite results. In conclusion, TAVI improves HrQoL more in high to extreme than intermediate risk patients. Frailty's impact on HrQoL post-TAVI is inconclusive due to varying outcomes in RCTs vs. non-RCTs.

Physical Fitness Is Directly Related to Exercise Capacity and Ventilatory Response to Exercise in Men with HFrEF

Background: Heart failure (HF) patients experience reduced functional fitness level (determining the performance of routine, daily activities) and diminished exercise capacity (linked to more effortful activities). Aim: The aim of the study is to assess this relationship using functional fitness tests compared to peak VO2 and VE/VCO2 slope in the context of exercise capacity and ventilatory response to exercise. Methods: A total of 382 men with stable HFrEF (age: 61 ± 10, NYHA class I/II/III/IV: 16/50/32/2%, LVEF: 30.5 ± 8.3%) underwent cardiopulmonary exercise testing (CPX) and a Senior Fitness Test (SFT). Afterwards, the patients were divided according to the 2capacity with peak VO2 ≥ 18 mL/kg/min, those with higher or lower ventilatory responses (VE/VCO2 slope ≥ 35 vs. <35) to the exercise were compared. Results: Patients who covered shorter distances in the 6 min walking test showed worse results in the functional tests ('stand up and go', 'chair stand' and 'arm curl') and CPX (lower peak VO2, shorter exercise time and higher VE/VCO2 slope). Subjects classified into Class D demonstrated the worst results in all elements of SFT; those in Class A demonstrated the best results. Significant differences that were analogous occurred also between classes B and C. Among the participants who reached peak VO2 ≥ 18 mL/kg/min (n = 170), those with VE/VCO2 slope ≥ 35 were characterized by worse physical fitness as compared to those with VE/VCO2 < 35. Conclusion: Reduced exercise tolerance led to worsening physical function in patients with HFrEF. Moreover, limitations in physical fitness seem to be distinctive for those patients showing excessive ventilatory response to exercise slope VE/VCO2 (≥35). The Senior Fitness Test may be considered as a useful tool for assessing comprehensive functional and clinical status and risk stratification in patients with HFrEF, especially those with extremely low exercise capacity.

Impact of the Barthel Index Score and Prognosis on Patients Undergoing Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement

BACKGROUND

Few studies have compared the Barthel Index (BI) score and postoperative outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). We aimed to examine the relationship between the BI score and postoperative outcomes in patients who underwent TAVR and SAVR.

METHODS AND RESULTS

The study included patients who underwent SAVR between January 2014 and December 2022 (n=293) and patients who underwent TAVR between January 2016 and December 2022 (n=312). We examined the risk factors for long-term mortality in the 2 groups. The mean (±SD) preoperative BI score was 88.7±18.0 in the TAVR group and 95.8±12.3 in the SAVR group. The home discharge rate was significantly lower in the SAVR than TAVR group. The BI score at discharge was significantly higher in the SAVR than in TAVR group (86.2 vs. 80.2; P<0.001). Significant risk factors for long-term mortality in the TAVR group were sex (P<0.001) and preoperative hemoglobin level (P=0.008), whereas those in the SAVR group were preoperative albumin level (P=0.04) and postoperative BI score (P=0.02). The cut-off point of the postoperative BI score determined by receiver operating characteristic curve analysis was 60.0.

CONCLUSIONS

The BI score at discharge was a significant risk factor for long-term mortality in the SAVR group, with a cut-off value of 60.0.

Predictors for all-cause mortality in men after transcatheter aortic valve replacement: A report from the LAPLACE-TAVI registry

Background

Information regarding the outcomes of transcatheter aortic valve replacement (TAVR) in men is limited. This study aimed to investigate short- to mid-term outcomes and prognostic predictors in this population.

Method and Results

The data of 519 men were analyzed from 1,693 consecutive patients with symptomatic severe aortic stenosis who underwent TAVR at six hospitals between April 2010 and July 2020. The primary endpoint was all-cause mortality at 30 days after TAVR. The mean age and Society of Thoracic Surgeons (STS) score were 83.7 ± 5.9 years and 6.3 ± 4.7%, respectively. Overall, 23.5% of patients consumed alcohol with a frequency of > 1 drinks/week, and 12.1% consumed alcohol with a frequency of > 8 drinks/week, while 66.1% were former smokers and 4.2% were current smokers. Mortality at 30 days was 0.8%. During the median follow-up period of 448 days, the estimated survival rates at 1 year post-TAVR was 90.7 ± 1.4%. In multivariate analysis, the serum albumin level [hazard ratio (HR): 2.20, 95% confidence interval (CI):1.36-3.62, p = 0.001], atrial fibrillation (HR: 1.79, 95% CI: 1.13-2.82, p = 0.012), and STS score (HR: 1.33, 95% CI: 1.06-1.67, p = 0.015) were independently associated with all-cause mortality following TAVR. Adjusted hazard ratios of current smoking, heavy drinking, and presence of cancer were 1.05 (95% CI: 0.36-2.98),1.37 (95% CI: 0.75-2.48), and 1.13 (95% CI: 0.75-2.48), respectively.

Conclusion

Our study demonstrated that serum albumin levels, atrial fibrillation, and STS score were independently associated with all-cause mortality following TAVR in men.

Association of red blood cell distribution width-to-albumin ratio with mortality in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Frailty is associated with poor prognosis in patients undergoing transcatheter aortic valve replacement (TAVR). The red blood cell distribution width (RDW)-to-albumin ratio (RAR) reflects key components of frailty. This study aimed to evaluate the relationship between RAR and all-cause mortality in patients undergoing TAVR.

METHODS

The data were extracted from the Medical Information Mart for Intensive Care IV database. The RAR was computed by dividing the RDW by the albumin. The primary outcome was all-cause mortality within 1-year following TAVR. The association between RAR and the primary outcome was evaluated using the Kaplan-Meier survival curves, restricted cubic spline (RCS), and Cox proportional hazard regression models.

RESULTS

A total of 760 patients (52.9% male) with a median age of 84.0 years were assessed. The Kaplan-Meier survival curves showed that patients with higher RAR had higher mortality (log-rank P < 0.001). After adjustment for potential confounders, we found that a 1 unit increase in RAR was associated with a 46% increase in 1-year mortality (HR = 1.46, 95% CI:1.22-1.75, P < 0.001). According to the RAR tertiles, high RAR (RAR > 4.0) compared with the low RAR group (RAR < 3.5) significantly increased the risk of 1-year mortality (HR = 2.21, 95% CI: 1.23-3.95, P = 0.008). The RCS regression model revealed a continuous linear relationship between RAR and all-cause mortality. No significant interaction was observed in the subgroup analysis.

CONCLUSION

The RAR is independently associated with all-cause mortality in patients treated with TAVR. The higher the RAR, the higher the mortality. This simple indicator may be helpful for risk stratification of TAVR patients.

Efficacy and Safety of Home-Based Cardiac Telemonitoring Rehabilitation in Patients After Transcatheter Aortic Valve Implantation: Single-Center Usability and Feasibility Study

BACKGROUND

No consensus exists on the efficacy of home-based cardiac rehabilitation (CR) in patients who have undergone transcatheter aortic valve implantation (TAVI). Additionally, there are no reports on home-based cardiac telemonitoring rehabilitation (HBTR) in patients after TAVI.

OBJECTIVE

We aimed to investigate the efficacy of HBTR in patients who have undergone TAVI.

METHODS

This single-center preliminary study introduced HBTR to patients after TAVI, and the efficacy outcomes of the rehabilitation method were compared to that of a historical control cohort. The historical control cohort (control group) consisted of 6 consecutive patients who underwent ordinary outpatient CR after TAVI from February 2016 to March 2020. Patients who participated in the HBTR program were only recruited after the TAVI procedure and before discharge between April 2021 and May 2022. In the first 2 weeks after TAVI, patients underwent outpatient CR and were trained using telemonitoring rehabilitation systems. Thereafter, patients underwent HBTR twice a week for 12 weeks. The control group performed standard outpatient CR at least once a week for 12 to 16 weeks. Efficacy was assessed using peak oxygen uptake (VO₂) prior to and after CR.

RESULTS

Eleven patients were included in the HBTR group. All patients underwent 24 HBTR sessions during the 12-week training period, and no adverse events were observed. The control group participants performed 19 (SD 7) sessions during the training period, and no adverse events were observed. Participants in the HBTR and control groups had a mean age of 80.4 (SD 6.0) years and 79.0 (SD 3.9) years, respectively. In the HBTR group, preintervention and postintervention peak VO₂ values were 12.0 (SD 1.7) mL/min/kg and 14.3 (SD 2.7) mL/min/kg (P=.03), respectively. The peak VO₂ changes in the HBTR and control groups were 2.4 (SD 1.4) mL/min/kg and 1.3 (SD 5.0) mL/min/kg (P=.64), respectively.

CONCLUSIONS

Home-based CR using a telemonitoring system is a safe outpatient rehabilitation method. Its efficacy is not inferior to that of standard CR in patients who have undergone TAVI.

TRIAL REGISTRATION

Japan Registry of Clinical Trials jRCTs032200122; https://jrct.niph.go.jp/latest-detail/jRCTs032200122.

Physical Performance in Black and Hispanic Outpatients with Heart Failure: The SCAN-MP Study

Background

Deficits of physical function are associated with poor quality of life and adverse health outcomes, but data informing the association of these assessments among Black and Hispanic outpatients with heart failure (HF) are limited.

Methods

The multicentre, prospective Screening for Cardiac Amyloidosis With Nuclear Imaging for Minority Populations (SCAN-MP) study identified Black and Hispanic subjects with stable HF, collected baseline characteristics, and took measures using the short physical performance battery. Subjects completed a Kansas City Cardiomyopathy Questionnaire (KCCQ), and the clinical outcomes of HF hospitalization and death were ascertained by telephone and review of the electronic health record.

Results

Of 320 participants, 227 (70.9%) had physical deficits, defined by a battery score of ≤ 9. Patients with severe physical deficits reported overall lower KCCQ scores compared to those with no deficits (KCCQ score of 57.0 vs 72.4, P < 0.001). Physical limitation was significantly associated with risk of HF hospitalization, after adjustments for age, sex, and New York Heart Association class (severe physical deficit hazard ratio, 3.61; 95% confidence interval [CI], 1.19-10.93; P = 0.024; mild physical deficit hazard ratio, 2.59; 95% CI, 0.86-7.75; P = 0.090).

Conclusions

Reduced physical performance is highly prevalent among Black and Hispanic outpatients with HF, and it is associated with overall KCCQ score, as well as an increased risk for HF hospitalization.

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.

Risk Factors for Hospital Readmission Post-Transcatheter Aortic Valve Implantation in the Contemporary Era: A Systematic Review

Background

Despite transcatheter aortic valve implantation (TAVI) becoming a widely accepted therapeutic option for the management of aortic stenosis, post-procedure readmission rates remain high. Rehospitalization is associated with negative patient outcomes, as well as increased healthcare costs, and has therefore been identified as an important target for quality improvement. Strategies to reduce the post-TAVI readmission rate are needed but require the identification of patients at high risk for rehospitalization. Our systematic review aims to identify predictors of post-procedure readmission in patients eligible for TAVI.

Methods

We conducted a comprehensive search of the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for the time period from 2015 to the present for articles evaluating risk factors for rehospitalization post-TAVI with a follow-up period of at least 30 days in adults age ≥ 70 years with aortic stenosis. The quality of included studies was evaluated using the Newcastle-Ottawa Scale. We present the results as a qualitative narrative review.

Results

We identified 49 studies involving 828,528 patients. Post-TAVI readmission is frequent, and rates vary (14.9% to 54.3% at 1 year). The most-frequent predictors identified for both 30-day and 1-year post-TAVI readmission are atrial fibrillation, lung disease, renal disease, diabetes mellitus, in-hospital life-threatening bleeding, and non-femoral access.

Conclusions

This systematic review identifies the most-common predictors for 30-day and 1-year readmission post-TAVI, including comorbidities and potentially modifiable procedural approaches and complications. These predictors can be used to identify patients at high-risk for readmission who are most likely to benefit from increased support and follow-up post-TAVI.

C-Reactive Protein to Albumin Ratio in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVE

To evaluate whether the serum C-reactive protein to albumin ratio (CAR) could be used for risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS).

PATIENTS AND METHODS

Frailty is a predictor of poor outcomes in patients undergoing AS interventions. The CAR reflects key components of frailty (systemic inflammation and nutrition) and could potentially be implemented into assessment and management strategies for patients with AS. From March 1, 2010, through February 29, 2020, 1836 patients were prospectively enrolled in an observational TAVR database. Patients (prospective development cohort, n=763) were grouped into CAR quartiles to compare the upper quartile (CAR Q4) with the lower quartiles (CAR Q1-3). Primary end point was all-cause mortality. Results were verified in an independent retrospective cohort (n=1403).

RESULTS

The CAR Q4 had a higher prevalence of impaired left ventricular function, atrial fibrillation, diabetes, and cerebrovascular disease and a higher median logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) vs CAR Q1-3. After median follow-up of 15.0 months, all-cause mortality was significantly higher in CAR Q4 vs CAR Q1-3 (P<.001). In multivariable analyses, risk factors for all-cause mortality were CAR Q4 (>0.1632; hazard ratio, 1.45; 95% confidence interval, 1.05 to 2.00; P=.03), N-terminal pro-B-type natriuretic peptide Q4 (>3230 pg/mL [to convert to ng/L, multiply by 1), high-sensitivity troponin T Q4 (>0.0395 ng/mL [to convert to μg/L, multiply by 1]), above-median logistic EuroSCORE (16.1%), myocardial infarction, Acute Kidney Injury Network stage 3, and life-threatening bleeding.

CONCLUSION

Elevated CAR was associated with increased risk of all-cause mortality in patients undergoing transfemoral TAVR. The CAR, a simple, objective tool to assess frailty, could be incorporated into assessing patients with AS being considered for TAVR.

Prevalence, Characteristics, and Impact of Frailty in Patients with Functional Tricuspid Regurgitation

Little is known as regards frailty in patients with functional tricuspid regurgitation (FTR). Thus, in this study, we aimed to investigate the prevalence, characteristics, and impact of frailty on patients with severe FTR.This prospective study included 110 consecutive patients with severe FTR who were assessed via transthoracic echocardiography at an outpatient clinic. Patients were dichotomized using short physical performance battery (SPPB). To better understand the whole picture of frailty in patients with FTR, other frailty scales were also assessed (frailty checklist, clinical frailty scale, gait speed, and Columbia frailty scale). The primary endpoint was the combination of all-cause mortality and heart failure hospitalization.According to each definition of frailty, 28%-46% were identified to be frail. Those with SPPB score of < 9 were older, had greater New York Heart Association (NYHA) functional classification, and had lower albumin level and estimated glomerular filtration rate compared with those with SPPB score of ≥ 9. They also have smaller tricuspid valve coaptation depth and worse right ventricular fractional area change (RV-FAC) than those with SPPB score of ≥ 9 despite having similar TR severity. The primary endpoint at 1 year was noted in 31% of patients. The SPPB score has excellent discriminatory performance for predicting the primary endpoint (area under the curve 0.82, 95% confidence interval [CI] 0.76-0.91) in receiver operating characteristic analysis and was independently associated with the primary endpoint after adjustment in multivariate analysis (adjusted hazard ratio 0.81, 95% CI, 0.73-0.90; P < 0.001).Frailty has been widely prevalent in the elderly patient population with FTR; in fact, it has been determined to be strong parameter for poor outcomes.

A single-center analysis of outcomes, risk factors, and new valves in Asian patients treated with early transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) continues to expand as an optimal treatment in Western countries; however, Asian countries have been slower to adopt this procedure. This research aimed to explore the outcomes and status of early TAVI performed at a single center in Asia, and provide comparative outcomes of the newly designed Chinese valves.

Methods

We enrolled 175 consecutive patients who successfully underwent TAVI from September 2012 to January 2018 at Fuwai Hospital (Beijing, China). After a preliminary assessment of age, we included 109 older patients (≥69 years) who underwent surgical aortic valve replacement (SAVR) during the same period. The primary endpoint was all-cause mortality. The inverse probability of treatment weighting (IPTW) was used to reduce potential bias. Cox regression was used to identify the risk factors of a poor prognosis.

Results

The TAVI cohort had higher rates of all-cause mortality [11.4% vs. 2.4%, hazard ratio (HR): 4.79, 95% confidence interval (CI): 1.47 to 15.57, IPTW-adjusted P=0.009] and permanent pacemaker implantation (PPI; 14.6% vs. 1.6%, HR: 9.98, 95% CI: 2.71 to 36.67, IPTW-adjusted P<0.001) at 3 years than the SAVR cohort. In the multivariable Cox regression analysis based on the entire sample, liver disease was associated with all-cause mortality (HR: 5.080, 95% CI: 1.067 to 24.174, P=0.041). A smoking history was associated with an increased risk of postoperative heart failure (HF) (HR: 4.902, 95% CI: 1.265 to 18.999, P=0.022). Additionally, age (HR: 1.141, 95% CI: 1.010 to 1.288, P=0.034) and diabetes (HR: 7.301, 95% CI: 2.414 to 22.079, P<0.001) were identified as predictors of postoperative stroke. In the new valve subgroups, the 1-year composite endpoints were 38.2% (Venus A), 35.3% (TaurusOne), 34% (J-Valve), and 28% (VitaFlow) (P=0.857).

Conclusions

Not all TAVI procedures had satisfactory outcomes compared with SAVR when initiated. At first, our center faced some challenges in delivering TAVI, and this is probably one of the reasons why the use of TAVI has developed slowly in Asia. Further investigations are needed to explore the underlying factors precluding the rapid expansion of TAVI in Asia.

Impact of Severe Sarcopenia on Rehospitalization and Survival One Year After a TAVR Procedure in Patients Aged 75 and Older

BACKGROUND

Transcatheter aortic-valve replacement (TAVR) reduces mortality and improves quality of life in patients with severe aortic valve stenosis. One third of patients have no benefit one year after TAVR. Sarcopenia, an age-related loss of skeletal muscle mass, is associated with increased physical disability and mortality. The main purpose was to evaluate the impact of severe sarcopenia on rehospitalization one year after TAVR in older patients.

METHODS

All patients aged ≥75 referred for a TAVR in 2018 were included. Severe sarcopenia was defined by a loss of skeletal muscle mass defined on CT-scan measurement associated with a gait speed ≤0.8m/s. The main outcome was rehospitalization one year after TAVR.

RESULTS

Median age of the 182 included patients was 84, and 35% had an unplanned hospitalization at one year. Severe sarcopenia was diagnosed in 9 patients (4.9%). Univariable analysis showed that gait speed was a factor associated with readmission [HR=0.32, 95% CI (0.10-0.97), p=0.04] but not severe sarcopenia. In multivariable analysis, only diabetes was significantly associated with rehospitalization [HR=2.06, 95% CI (1.11-3.84), p=0.02]. Prevalence of severe sarcopenia varied according to different thresholds of skeletal muscle mass on CT-scan.

CONCLUSION

Even though severe sarcopenia was not correlated with rehospitalization and mortality at one year after TAVR, our results emphasize the changes in the prevalence according to cutoff used. It highlights the need to define standardized methods and international threshold for sarcopenia diagnosis by CT-scan measurements, in general population and for patients with valvular heart disease.

Psoas Muscle Volume and Attenuation are Better Predictors than Muscle Area for Hospital Readmission in Older Patients after Transcatheter Aortic Valve Implantation

OBJECTIVE

This study aimed to determine whether the psoas muscle volume (PMV) and its muscle attenuation (MA) are associated with hospital readmission after transcatheter aortic valve implantation (TAVI).

METHOD

We included 113 older patients with aortic stenosis who underwent TAVI at Sakakibara Heart Institute (mean age 85 ± 5 years, 69% women). We measured PMV and psoas muscle area (PMA) as well as total muscle area (TMA) at the third lumbar vertebra using preoperative computed tomography (CT) images. The crude values of the PMV, PMA, and TMA were normalized by dividing by height squared.

RESULTS

The median follow-up period was 724 days (interquartile range: 528-730 days), and there were 25 all-cause readmissions during the follow-up period (22% of all patients). In the multivariate Cox regression analysis adjusted for age, sex, and EuroSCORE II, the PMV and its MA and crude PMA were significantly associated with all-cause readmission [HR: 0.957 (0.930-0.985), p = 0.003, HR: 0.927 (0.862-0.997), p = 0.040], whereas the PMA and TMA and each MA were not (all p > 0.05). The groups with low PMV and MA had significantly higher incidences of all-cause readmission than that with high PMV and MA (log-rank test: p = 0.011).

CONCLUSION

PMV and its MA measured from preoperative CT images were independent predictors of all-cause readmission in TAVI patients.

Impact of perioperative change in physical function on midterm outcomes after transcatheter aortic valve implantation

Preoperative frailty diminishes the potential for functional recovery after transcatheter aortic valve implantation (TAVI). However, perioperative changes in physical status and their impact on prognosis after TAVI have not previously been reported. Therefore, this study aimed to investigate whether perioperative changes in physical function affect prognosis in patients undergoing TAVI. We retrospectively reviewed 257 patients who underwent TAVI. The Short Physical Performance Battery (SPPB), an objective physical status assessment tool, was evaluated pre- and post-TAVI. Patients were divided into two groups: (i) patients whose SPPB score declined in the perioperative period (the decline group) and (ii) patients whose SPPB score did not decline in the perioperative period (the non-decline group). The primary endpoint was unplanned hospitalization owing to heart failure or cardiovascular death following TAVI. The mean follow-up period was 385 ± 151 days, mean age was 83.2 ± 5.8 years, and 67% of the patients were women. Sixteen patients required readmission owing to heart failure, and seven experienced cardiovascular-related death. Kaplan-Meier analysis revealed that the event-free rate was significantly lower in the decline group (log-rank, p = 0.006). A stepwise multivariate logistic regression analysis showed that a perioperative change in SPPB was significantly associated with primary endpoints (odds ratio, 1.51; 95% confidence interval, 1.12-2.04). Perioperative change in physical function was an independent risk factor for heart failure, hospitalization, or cardiovascular death following TAVI.

Five-Meter Walk Test as a Predictor of Prolonged Index Hospitalization After Transcatheter Aortic Valve Implantation

There are no studies evaluating comprehensive predictors of transcatheter aortic valve implantation (TAVI) outcomes encompassing frailty assessments in a South-East Asian cohort. In this longitudinal single-center cohort, all patients who underwent TAVI in a tertiary cardiac center and comprehensively assessed for frailty at baseline were included in a registry. The primary outcome was to investigate frailty indices predictive of prolonged index hospitalization after TAVI. Seventy-six patients with a mean age of 77.6 ± 8.5 years were included. Mean Society of Thoracic Society Predicted Risk of Mortality score was 5.2 ± 3.0, with 11 (14.5%) patients classified as high-risk (Society of Thoracic Society Predicted Risk of Mortality >8). Mean and median index hospitalization duration were 9.2 ± 5.6 and 7 [4.5 to 9.5] days, respectively. Univariate analysis demonstrated that lower hemoglobin (Hb) (p <0.01), longer 5-meter walk test (5MWT) (p <0.01), lower dominant hand grip strength (p <0.01), the use of transaortic access (p = 0.01), new atrial fibrillation post-TAVI (p <0.01), and lower postprocedural Hb (p <0.01) were associated with longer index hospitalization duration. Multivariate linear regression demonstrated preoperative Hb, preoperative atrial fibrillation and 5MWT were independent baseline predictors of index hospitalization duration (p <0.05). Additionally, a 5MWT cutoff of 11 seconds (0.45 m/s) had a high specificity (88.6%) in predicting prolonged index hospitalization duration. In conclusion, this is the first comprehensive frailty assessment in a South-East Asian cohort demonstrating 5MWT to be a significant predictor of prolonged index hospitalization. This simple and effective frailty assessment index may be considered to optimize patient selection for TAVI.

Transcatheter aortic valve implantation-related futility: prevalence, predictors, and clinical risk model

Futility denotes failure to achieve the projected outcome. We investigated the prevalence, predictors, and clinical risk model of transcatheter aortic valve implantation (TAVI)-related futility. We included 464 consecutive patients undergoing TAVI from 2010 to 2017. Futility was defined as death and/or hospitalization for heart failure (HFH) within 1 year after TAVI. Of 464 patients (mean age: 84.4 years), 69% were females (EuroSCOREII: 6.3%; Society of Thoracic Surgeons [STS] score: 6.9%). Forty-six patients (9.9%) experienced TAVI-related futility, and 36 of 46 patients (69.6%) died within 1 year due to cardiac (37.5%) and non-cardiac (62.5%) causes. Previous HFH (hazard ratio [HR], 2.20; 95% confidence interval [CI]: 1.13-4.35, p = 0.020), chronic obstructive pulmonary disease (COPD) (HR, 3.39; 95% CI: 1.12-8.42, p = 0.033), and moderate/severe mitral or tricuspid regurgitation (HR, 2.98; 95% CI: 1.32-6.27, p = 0.010) were independent predictors of futility. With 1 point assigned to each predictor (total 0 point, futility low-risk; total 1 point, futility intermediate-risk; total 2-3 points, futility high-risk), the futility risk model clearly stratified individual futility risk into three groups (the freedom from futility at 1 year: 96.2%, 82.1%, and 67.9% each). Our futility risk model presented better discrimination than EuroSCOREII, and STS score (c-statistic: 0.73 vs. 0.68 vs. 0.67). Medical futility was recognized in 9.9% of patients undergoing TAVI. Previous HFH, COPD, and concomitant atrioventricular regurgitation were associated with futility. The risk model derived from three predictors showed good performance in predicting futility risk.

Predictors and Prognostic Impact of Nutritional Changes After Transcatheter Aortic Valve Replacement

BACKGROUND

Little is known about changes in nutritional status as an index of frailty on clinical outcomes after transcatheter aortic valve replacement (TAVR). This study aimed to assess the clinical impact of serum albumin changes after TAVR.

METHODS

Changes in serum albumin levels from baseline to 1 year after TAVR were evaluated in 1524 patients who were classified as having hypoalbuminemia (<3.5 g/dl) and normoalbuminemia (≥3.5 g/dl) at each timepoint. The patients were categorized into 4 groups: NN (baseline normoalbuminemia, 1-year normoalbuminemia: n = 1119), HN (baseline hypoalbuminemia, 1-year normoalbuminemia: n = 202), NH (baseline normoalbuminemia, 1-year hypoalbuminemia: n = 121), and HH (baseline hypoalbuminemia, 1-year hypoalbuminemia: n = 82). We also defined late hypoalbuminemia as hypoalbuminemia identified at the 1-year assessment. Clinical outcomes were compared among 4 groups. Multivariable analysis was driven to assess the variables associated with late hypoalbuminemia and long-term mortality.

RESULTS

The cumulative 3-year mortality was significantly different among the 4 groups (NN: 11.4%, HN: 10.7%, NH: 25.4%, HH: 44.4%, p < 0.001). Multivariable Cox regression analysis revealed that the NH group had a higher mortality risk (hazard ratio [HR]; 2.80 and 3.53, 95% confidence interval [CI]; 1.71-4.57 and 2.06-6.06, p < 0.001 and p < 0.001, respectively), whereas the HN group had a similar risk (HR; 1.16, 95% CI; 0.66-2.06, p = 0.61) compared with the NN group. Baseline hypoalbuminemia, low body mass index, liver disease, peripheral artery disease, and hospital readmission within 1 year were predictors of late hypoalbuminemia (all p < 0.05).

CONCLUSION

Serial albumin assessment may identify poor prognostic subsets in patients with persistent and late acquired malnutrition after TAVR.

Modified essential frailty toolset to determine outcomes following transcatheter aortic valve replacement

BACKGROUND

Several predictors are available to guide patient selection for transcatheter aortic valve replacement (TAVR) to achieve better outcomes, and the essential frailty toolset (EFT) has been reported as one of those predictors. This study investigated whether a modified EFT could independently predict all-cause mortality following TAVR.

METHODS

The study population comprised 176 consecutive patients with severe aortic stenosis whose frailty was assessed with a modified EFT prior to TAVR at the Sakakibara Heart Institute between 2013 and 2018. The primary endpoint was all-cause mortality following TAVR. To understand the association between the modified EFT and all-cause mortality, multivariate Cox regression analysis was performed. In addition, to understand its predictive performance, we conducted a receiver operating characteristic (ROC) analysis.

RESULTS

Patients were elderly, relatively frail, and were likely to have significant heart failure symptoms. By the modified EFT definition, 40 patients (22.7%) were considered frail. With a median follow up of 1145 days, all-cause mortality at 1, 2, and 3 years was 6.2%, 10.2%, and 18.3%, respectively. Patients assessed as more frail on the clinical frailty scale had higher modified EFT scores. In ROC analysis, the area under the curve for predicting all-cause mortality at 1, 2, and 3 years was 0.79 [95% confidence interval (CI) 0.68-0.90]; 0.74 (95% CI 0.62-0.84); and 0.67 (95% CI 0.56-0.79), respectively, with the best cut-off modified EFT score of 1/2.

CONCLUSIONS

The modified EFT score was independently associated with all-cause mortality and had excellent predictive performance for all-cause mortality at 1 year.

Usefulness of FRAIL Scale in Heart Valve Diseases

Background

The frailty syndrome is a serious health problem for an aging population. The occurrence of frailty in the group of symptomatic patients undergoing heart valve surgery may have additional clinical implications. The predictive ability of the FRAIL scale in patients undergoing heart valve surgery during a 30-day follow-up has not yet been described.

Patients and Methods

A prospective study was conducted on a group of consecutive patients with hemodynamically significant valve disease (aortic stenosis, aortic regurgitation, mitral stenosis and mitral regurgitation) that underwent elective valve surgery in 2014–2019. The primary endpoint was 30-day mortality. Univariate analysis, followed by multivariate regression analysis, was performed.

Results

The study group included 672 consecutive patients (aortic valve stenosis, aortic regurgitation, mitral stenosis and mitral regurgitation) who underwent replacement or repair of the valve. Twenty-five patients died during the 30-day follow-up. At multivariate analysis, FRAIL scale result (OR 2.802; 95% CI 1.275–6.157; p=0.01) and red cell distribution width (RDW) (OR 1.810; 95% CI 1.181–2.775; p=0.006) remained independent predictors of the primary endpoint.

Conclusion

The presented study showed the predictive ability of the FRAIL scale result in patients undergoing heart valve surgery for 30-day mortality.

Prevalence and Prognostic Implications of Frailty in Transcatheter Aortic Valve Replacement

Assessment of frailty has become engrained in the preprocedural evaluation of older adults referred for transcatheter aortic valve replacement. Addition of frailty and disability to clinical risk scores results in improved discrimination for short- and midterm mortality and identifies patients less likely to be discharged home and more likely to report worsening quality of life over the ensuing 6 to 12 months. In clinical practice, frailty can be evaluated by a tiered approach starting with a brief screening tool such as the Essential Frailty Toolset.

Predictors of survival in patients undergoing cardiac rehabilitation after transcatheter aortic valve implantation

AIMS

Cardiac rehabilitation may improve physical and functional recovery after transcatheter aortic valve implantation (TAVI), but outcome predictors in TAVI patients are usually based on assessments made before or at the time of TAVI without regard to cardiac rehabilitation referral. We aimed to assess exercise-based cardiac rehabilitation-derived parameters that may predict 3-year outcome in TAVI patients undergoing residential cardiac rehabilitation.

METHODS AND RESULTS

In 95 consecutive TAVI patients (82.7 ± 4.9 years, 65% women) who underwent a 3-week cardiac rehabilitation program, at 3-year follow-up 35 deaths occurred. Compared with survivors, nonsurvivors had longer stay in cardiac rehabilitation (29.5 ± 12.3 vs. 21.6 ± 7.5 days, P = 0.0001), worse serum creatinine at admission/discharge (1.59 ± 0.86 vs. 1.26 ± 0.43 mg/dl, P = 0.0164; 1.52 ± 0.61 vs. 1.23 ± 0.44 mg/dl, P = 0.011), higher Cumulative Illness Rated State Comorbidity Index (5.4 ± 1.5 vs. 4.6 ± 1.8, P = 0.036) and Barthel Index at admission/discharge (51.8 ± 24.5 vs. 68.1 ± 23.2, P = 0.0016; 73.5 ± 27.2 vs. 88.6 ± 15.3, P = 0.0007), higher Morse Fall Risk score (35.6 ± 24 vs. 24.3 ± 14.1, P = 0.0056), and were less likely to train above the median exercise workload (fit) (11 vs. 35%, P = 0.008) or perform the 6-min walk test (6MWT) at admission/discharge (NO-6MWT: 34 vs. 12%, P = 0.008) and walked less distance on admission (6MWT: 129.6 ± 88.3 vs. 193.3 ± 69.8 m, P = 0.008). Univariate predictors of 3-year survival were cardiac rehabilitation duration, serum creatinine, Cumulative Illness Rated State Comorbidity Index, Barthel Index and NO-6MWT at admission/discharge, 6MWT at admission, Morse Fall Risk score at discharge and fit. Multivariate analysis confirmed exercise tolerance, Barthel Index and sCr at discharge as predictors.

CONCLUSION

In TAVI patients who undergo cardiac rehabilitation, lower exercise tolerance, higher Barthel Index and sCr at discharge may predict 3-year mortality.

Effects of acute-phase multidisciplinary rehabilitation on unplanned readmissions after cardiac surgery

OBJECTIVES

The provision of inpatient programs that reduce the incidence of readmission after cardiac surgery remains challenging. Investigators have focused on multidisciplinary cardiac rehabilitation (CR) because it reduces the postoperative readmission rate; however, most previous studies used outpatient models (phase II CR). We retrospectively investigated the effect of comprehensive multidisciplinary interventions in the acute inpatient phase (phase I CR) on unplanned hospital readmission.

METHODS

In a retrospective cohort study, we compared consecutive patients after cardiac surgery. We divided them into the multidisciplinary CR (multi-CR) group or conventional exercise-based CR (conv-CR) group according to their postoperative intervention during phase I CR. Multi-CR included psychological and educational intervention and individualized counseling in addition to conv-CR. The primary outcome was unplanned readmission rates between the groups. A propensity score-matching analysis was performed to minimize selection biases and the differences in clinical characteristics.

RESULTS

In our cohort (n = 341), 56 (18.3%) patients had unplanned readmission during the follow-up period (median, 419 days). Compared with the conv-CR group, the multi-CR group had a significantly lower unplanned readmission rate (multivariable regression analysis; hazard ratio, 0.520; 95% confidence interval, 0.28-0.95; P = .024). A Kaplan-Meier analysis of our propensity score-matched cohort showed that, compared with the conv-CR group, the multi-CR group had a significantly lower incidence of readmission (stratified log-rank test, P = .041).

CONCLUSIONS

In phase I, compared to conv-CR alone, multi-CR reduced the incidence of unplanned readmission. Early multidisciplinary CR can reduce hospitalizations and improve long-term prognosis after cardiac surgery.

Usefulness of the Transcatheter Aortic Valve Replacement Risk Score to Determine Mid-Term Outcomes

BACKGROUND

The purpose of this study was to investigate if the transcatheter aortic valve replacement (TAVR) risk score can independently predict outcomes following TAVR, and to evaluate its predictive performance.

METHODS AND RESULTS

This retrospective multicenter study comprised 682 patients with severe aortic stenosis who underwent TAVR. The primary endpoint was all-cause death following TAVR. The clinical model was established using variables identified as independent predictors in the multivariate analysis. Incremental values were assessed after adding atrial fibrillation, body mass index (BMI), and serum albumin to the TAVR risk score in receiver-operating characteristic analysis. The median TAVR risk score was 2.1% with a mean follow-up of 505 days. On Kaplan-Meier analysis, a TAVR risk score >4% had lowest survival rate, whereas TAVR risk score ≤2% had the highest survival rate at 3 years (log-rank P<0.001). The multivariate Cox regression analysis found the TAVR risk score was independently associated with all-cause death, and demonstrated moderate predictive performance for predicting all-cause death at 3 years. However, if each independent predictor is added to the model, it significantly increased discriminatory performance, particularly with BMI and serum albumin level.

CONCLUSIONS

We demonstrated that the TAVR risk score could independently predict mid-term death following TAVR, and had greater predictive performance for predicting all-cause death at 3 years with BMI and serum albumin level.

Physical performance as a predictor of midterm outcome after mitral valve surgery

The usefulness of performing physical function assessments for evaluating clinical outcomes after all cardiac surgeries has been reported. However, no studies have evaluated the relationship between physical function and prognosis in patients undergoing cardiac open surgery with mitral valve regurgitation (MR). This study investigated whether physical assessment, such as the short physical performance battery (SPPB), could predict unplanned readmission events in patients undergoing mitral valve surgery due to MR. SPPB could predict unplanned admission events in patients undergoing mitral valve surgery due to MR. This retrospective study included 168 patients who underwent mitral valve surgery. SPPB was performed 1.6 ± 1.1 days before surgery. The primary endpoint was unplanned readmission. The mean follow-up period was 762 ± 480 days, mean age was 73.8 ± 6.3 years, and 43% of the patients were women. Of the study patients, 46 required unplanned readmissions; 29 of these patients required readmissions within 1 year. Multivariate Cox regression analysis demonstrated that SPPB was independently associated with the primary endpoint. Receiver-operating characteristic analysis showed that SPPB had an area under the curve of 0.71, with an optimal cutoff of 11. The study patients were stratified into SPPB 12 or SPPB ≤ 11 groups. Kaplan-Meier analysis showed that the event-free rate was significantly lower in the SPPB ≤ 11 group (hazard ratio 3.8, 95% confidence interval 2.1-7.0; p < 0.001). SPPB was a useful tool for predicting unplanned readmission in patients undergoing mitral valve surgery due to MR.

Frailty and Exercise Training: How to Provide Best Care after Cardiac Surgery or Intervention for Elder Patients with Valvular Heart Disease

The aim of this literature review was to evaluate existing evidence on exercise-based cardiac rehabilitation (CR) as a treatment option for elderly frail patients with valvular heart disease (VHD). Pubmed database was searched for articles between 1980 and January 2018. From 2623 articles screened, 61 on frailty and VHD and 12 on exercise-based training for patients with VHD were included in the analysis. We studied and described frailty assessment in this patient population. Studies reporting results of exercise training in patients after surgical/interventional VHD treatment were analyzed regarding contents and outcomes. The tools for frailty assessment included fried phenotype frailty index and its modifications, multidimensional geriatric assessment, clinical frailty scale, 5-meter walking test, serum albumin levels, and Katz index of activities of daily living. Frailty assessment in CR settings should be based on functional, objective tests and should have similar components as tools for risk assessment (mobility, muscle mass and strength, independence in daily living, cognitive functions, nutrition, and anxiety and depression evaluation). Participating in comprehensive exercise-based CR could improve short- and long-term outcomes (better quality of life, physical and functional capacity) in frail VHD patients. Such CR program should be led by cardiologist, and its content should include (1) exercise training (endurance and strength training to improve muscle mass, strength, balance, and coordination), (2) nutrition counseling, (3) occupational therapy (to improve independency and cognitive function), (4) psychological counseling to ensure psychosocial health, and (5) social worker counseling (to improve independency). Comprehensive CR could help to prevent, restore, and reduce the severity of frailty as well as to improve outcomes for frail VHD patients after surgery or intervention.