Impact of frailty markers on outcomes after transcatheter aortic valve replacement: insights from a Japanese multicenter registry

Tumour necrosis factor-alpha serum level is an independent predictor of medium-term all-cause mortality after transcatheter aortic valve replacement

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a suitable treatment for patients with severe aortic stenosis and severely increased operative risk. There is need for a better preoperative risk assessment for TAVI candidates.

AIM

To determine whether Tumour necrosis factor-alfa (TNFα) is an independent predictor of survival 500 days after TAVI.

METHODS

Sixty patients undergoing TAVI were enrolled in the study. TNFα was determined. The CT measured low-density muscle fraction (LDM%) of the psoas muscle was determined. Operative risk assessment by Logistic EuroSCORE, EuroSCORE II, and STS score was performed. Frailty scores (FRAIL scale and Barthel index) were determined.

RESULTS

Mean age was 81.01 ± 7.54 years. Twenty-six (43.3%) of the patients were males. In the univariable analyses, FRAIL scale and Barthel index were no predictors of survival after TAVI. In the multivariable analysis, including EuroSCORE II, LDM% and TNFα serum concentration, TNFα serum level was an independent predictor of survival 500 days after TAVI (HR: 3.167; 95%: 1.279-7.842; p = 0.013). The multivariable analysis, including TNFα as a categorical variable, showed that compared to patients in the conjugated first and second TNFα serum level tertile, patients in the third tertile had a hazard ratio (HR) of 10.606 (95%CI: 1.203 - 93.467) (p = 0.033).

CONCLUSION

TNFα is an incremental independent predictor of long-term survival after TAVI.

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.

Pre-procedural serum albumin concentration is associated with length of stay, discharge destination, and 90-day mortality in patients after transcatheter aortic valve replacement

Background

As visceral protein expression may influence outcomes in patients with cardiovascular disease, we investigated whether pre-procedural albumin concentration is associated with length of stay (LOS) and 90-day mortality after transcatheter aortic valve repair (TAVR).

Methods

We retrospectively analyzed data from TAVR patients at our institution between January 2013 and December 2017. For all patients, baseline albumin concentration was assessed between one and four weeks before the procedure. To investigate the association between albumin concentration and outcomes, we performed regression analyses, controlling for Society of Thoracic Surgeons, New York Heart Association classification, and Kansas City Cardiomyopathy Questionnaire 12 scores.

Results

Three hundred eighty patients were included in the analyses. Cox-proportional hazards regression showed that patients with albumin concentrations <3.5 g/dL were 80% more likely to have prolonged ICU LOS (HR 1.79; 95%CI 1.04-2.57, P = 0.03) and 70% more likely to have prolonged hospital LOS (HR 1.68; 95%CI 1.01-2.46, P = 0.04) compared to patients with albumin concentrations >3.5 g/dL. Logistic regression showed that patients with albumin concentrations <3.5 g/dL were four times more likely to not survive to 90 days (OR 3.94; 1.13-12.63, P = 0.03) after their TAVR compared to patients with albumin concentrations >3.5 g/dL.

Conclusion

Our data suggest that patients with pre-procedural albumin concentrations <3.5 g/dL are at an increased risk of adverse outcomes after TAVR compared to patients with albumin concentrations ≥3.5 g/dL. Prospective studies are needed to determine whether risk stratification based on pre-procedural albumin can improve outcomes and whether targeted interventions can improve pre-procedural albumin concentrations in potential TAVR candidates.

Investigation on Imaging Features and Clinical Significance of Cardiac CT in Comprehensive Evaluation of Aortic Valve and Root before Percutaneous Aortic Valve Replacement

Medical imaging feature analysis is the basis of medical image processing and analysis. The solution of this problem not only directly affects the successful application of computer graphics and image technology in medicine but also has important theoretical and practical significance. In this paper, the imaging characteristics and clinical significance are discussed by studying the comprehensive evaluation of aortic valve and root before aortic valve replacement. In recent years, preoperative comprehensive evaluation of the aortic valve and root has been gradually carried out. Compared with traditional methods, minimally invasive surgery brings more accurate diagnosis to patients, quick recovery and discharge after surgery, and less pain. This study retrospectively includes patients with severe aortic stenosis who underwent TAVR with routine computed tomography. Based on CT images, the determination and grouping of bicuspid aortic valve and tricuspid aortic valve were completed. Thirteen cross-sectional levels of the aorta-iliac-femoral vascular access were completed. The results showed that 3 people had stroke (17.6%) and 5 people had myocardial infarction (29.4%) during the follow-up period. Atrial fibrillation occurred in 5 patients (29.4%), permanent pacemaker implantation was performed in 1 patient (5.9%), and acute kidney injury occurred in 7 patients (41.2%). No patient died due to surgery-related causes, and the analysis of imaging features and clinical significance in the preoperative comprehensive evaluation of the aortic valve and root played a crucial role. In the training stage, the principal component analysis method was used to train the shape, and the model of the shape intensity of the aortic valve and the shape change of each principal component was obtained. The most probable aortic valve region in the target image was obtained by matching the similarity of all atlases, and the correct aortic valve segmentation was obtained by using the first level set of shape intensity. The experimental part verified the accuracy of the algorithm.

Adiponectin serum level is an independent and incremental predictor of all-cause mortality after transcatheter aortic valve replacement

Background

Quantifiable biomarkers may be useful for a better risk and frailty assessment of patients referred for transcatheter aortic valve implantation (TAVI).

Hypothesis

To determine if adiponectin serum concentration predicts all‐cause mortality in patients undergoing TAVI.

Methods

77 consecutive patients, undergoing TAVI, were analyzed. The CT axial slices at the level of the fourth lumbar vertebra were used to measure the psoas muscle area, and its low‐density muscle fraction (LDM (%)). To assess the operative risk, the STS (Society of Thoracic Surgeons Predicted Risk of Mortality) score, Log. Euroscore, and Euroscore II were determined. A clinical frailty assessment was performed. ELISA kits were used to measure adiponectin serum levels. We searched for a correlation between serum adiponectin concentration and all‐cause mortality after TAVI.

Results

The mean age was 80.8 ± 7.4 years. All‐cause mortality occurred in 22 patients. The mean follow‐up was 1779 days (range: 1572–1825 days). Compared with patients with the lowest adiponectin level, patients in the third tertile had a hazards ratio of all‐cause mortality after TAVI of 4.155 (95% CI: 1.364–12.655) (p = .004). In the multivariable model, including STS score, vascular access of TAVI procedure, LDM (%), and adiponectin serum concentration, serum adiponectin level, and LDM(%) were independent predictors of all‐cause mortality after TAVI (p = .178, .303, .042, and .017, respectively). Adiponectin level was a predictor of all‐cause mortality in females and males (p = .012 and 0.024, respectively).

Conclusion

Adiponectin serum level is an independent and incremental predictor of all‐cause mortality in patients undergoing TAVI.

Low Circulating Musclin is Associated With Adverse Prognosis in Patients Undergoing Transcatheter Aortic Valve Implantation at Low-Intermediate Risk

Background

Musclin is an activity‐stimulated and cardioprotective myokine that attenuates pathological cardiac remodeling. Musclin deficiency, in turn, results in reduced physical endurance. The aim of this study was to assess the prognostic value of circulating musclin as a novel, putative biomarker to identify patients undergoing transcatheter aortic valve implantation (TAVI) who are at a higher risk of death.

Methods and Results

In this study, we measured systemic musclin levels in 368 patients undergoing TAVI who were at low to intermediate clinical risk (median EuroSCORE [European System for Cardiac Operative Risk Evaluation] II: 3.5; quartile 1–quartile, 2.2%–5.3%), whereby 209 (56.8%) patients were at low and 159 (43.2%) were at intermediate risk. Median preprocedural musclin levels were 2.7 ng/mL (quartile 1–quartile 3, 1.5–4.6 ng/mL). Musclin levels were dichotomized in low (<2.862 ng/mL, n=199 [54.1%]) or high (≥ 2.862 ng/mL, n=169 [45.9%]) groups using cutoff values determined by classification and regression tree analysis. The primary end point was 1‐year overall survival. Patients with low circulating musclin levels exhibited a significantly higher prevalence of frailty, low albumin values, hypertension, and history of stroke as well as higher N‐terminal pro‐B‐type natriuretic peptide. Low musclin levels significantly predicted risk of death in univariable (hazard ratio, 1.81; 95% CI, 1.00–3.53 [P=0.049]) and multivariable (adjusted hazard ratio, 2.45; 95% CI, 1.06–5.69 [P=0.037]) Cox regression analyses. Additionally, low musclin levels in combination with conventional EuroSCORE II suggested improved risk stratification in patients undergoing TAVI who were at low to intermediate clinical risk into subgroups with reduced 1‐year survival rates by log‐rank test (P for trend=0.003).

Conclusions

Circulating musclin is an independent predictor of 1‐year overall survival in patients undergoing TAVI. Combined with EuroSCORE II, circulating musclin might help to improve prediction of mortality in patients undergoing TAVI who are at low to intermediate clinical risk.

Development of a delirium predictive model for adult trauma patients in an emergency and critical care center: a retrospective study

Background

Delirium has been shown to prolong the length of intensive care unit stay, hospitalization, and duration of ventilatory control, in addition to increasing the use of sedatives and increasing the medical costs. Although there have been a number of reports referring to risk factors for the development of delirium, no model has been developed to predict delirium in trauma patients at the time of admission. This study aimed to create a scoring system that predicts delirium in trauma patients.

Methods

In this single-center, retrospective, observational study, trauma patients aged 18 years and older requiring hospitalization more than 48 hours were included and divided into the development and validation cohorts. Univariate analysis was performed in the development cohort to identify factors significantly associated with prediction of delirium. The final scoring system for predicting delirium was developed using multivariate analysis and internal validation was performed.

Results

Of the 308 patients in the development cohort, 91 developed delirium. Clinical Frailty Score, fibrin/fibrinogen degradation products, low body mass index, lactate level, and Glasgow Coma Scale score were independently associated with the development of delirium. We developed a scoring system using these factors and calculated the delirium predictive score, which had an area under the curve of 0.85. In the validation cohort, 46 of 206 patients developed delirium. The area under the curve for the validation cohort was 0.86, and the calibration plot analysis revealed the scoring system was well calibrated in the validation cohort.

Discussion

This scoring system for predicting delirium in trauma patients consists of only five risk factors. Delirium prediction at the time of admission may be useful in clinical practice.

Level of evidence

Prognostic and epidemiological, level III.

One-year outcomes of the pivotal clinical trial of a balloon-expandable transcatheter aortic valve implantation in Japanese dialysis patients

BACKGROUND

Dialysis patients with aortic stenosis are generally considered as being at extreme or high surgical risk. Herein, the first clinical trial was conducted to investigate clinical safety and effectiveness of transcatheter aortic valve replacement (TAVR) using the balloon-expandable transcatheter aortic valve (SAPIEN 3, Edwards Lifesciences, Irvine, CA, USA) in Japanese dialysis patients.

METHODS

The clinical trial is a single arm, prospective, open, non-randomized, Japanese multicenter study. The primary purpose of this trial is to evaluate the efficacy and safety of TAVR using SAPIEN 3 in 28 Japanese dialysis patients.

RESULTS

Mean age was 79.2 years and 67.9% were male (Mean STS score was 14.3%). Transfemoral and transapical approaches were performed in 25 (89.3%) and 3 patients (10.7%), respectively. All bioprostheses were successfully implanted. Median intensive care unit stay and hospital stay after TAVR were 1.4 days and 6.3 days, respectively. In-hospital mortality was 3.6% and freedom from all-cause mortality at 1 year was 89.3%. Disabling stroke and life-threatening bleeding at 1 year was 7.7% and 8.5%, respectively. There was no structural valve deterioration during follow-up. New York Heart Association functional status, six-minute walk test, and EuroQOL visual analogue scale score significantly improved through 1 year compared with baseline.

CONCLUSIONS

TAVR using SAPIEN 3 is safe and effective for the treatment of Japanese dialysis patients with symptomatic severe aortic valve stenosis.

Prognostic value of cardiac 123 I-metaiodobenzylguanidine imaging for predicting cardiac events after transcatheter aortic valve replacement

Aims

In patients with aortic valve stenosis (AS), cardiac sympathetic nervous (CSN) dysfunction and its improvement after transcatheter aortic valve replacement (TAVR) have been reported. The prognostic impact of CSN function remains unclear. This study investigated the prognostic value of cardiac ¹²³I‐metaiodobenzylguanidine (MIBG) imaging for predicting cardiac events after TAVR.

Methods and results

This single‐centre prospective observational study enrolled patients with AS between July 2017 and May 2019. MIBG scintigraphy was performed before and soon after TAVR to evaluate the late heart–mediastinum ratio (L‐H/M). Patients were classified into three pairs of groups based on the baseline and post‐TAVR L‐H/M (≥2.0 or <2.0) and on the presence of TAVR‐related improvement in L‐H/M. The study endpoint was the occurrence of major adverse cardiac events (MACE), defined as a composite of all‐cause death, non‐fatal myocardial infarction, and hospitalization due to heart failure. Among the 187 consecutive patients who underwent TAVR, 107 (27 men; median age: 86 years) were evaluated. Over a median follow‐up of 366 days, 15 (14.0%) patients had MACE. The incidence of MACE was significantly low in patients with L‐H/M improvement and/or high post‐TAVR L‐H/M (≥2.0). Baseline L‐H/M and frailty were associated with poor response of L‐H/M to TAVR treatment. TAVR‐related improvement in L‐H/M had significant effects on MACE, with an adjusted hazard ratio of 0.233 (95% confidence interval, 0.064–0.856; P = 0.028).

Conclusions

TAVR‐related improvement in L‐H/M was an independent predictor of cardiac events, 1 year after TAVR. Cardiac MIBG imaging is useful for predicting cardiac events after TAVR.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Gait Speed and 1-Year Mortality Following Cardiac Surgery: A Landmark Analysis From the Society of Thoracic Surgeons Adult Cardiac Surgery Database

Background

In older adults undergoing cardiac surgery, prediction of downstream risk is critical. Our objective was to determine the association of 5‐m gait speed with 1‐year mortality and repeat hospitalization following cardiac surgery.

Methods and Results

In this prospective cohort of patients undergoing cardiac surgery at centers participating in the Society of Thoracic Surgeons Database with gait speed recorded, we examined all‐cause mortality using a landmark analysis at 0 to 30, 30 to 365, and >365 days, as well as repeat hospitalization. The cohort consisted of 8287 patients (median age, 74 years; 32% females). At 1 year, survival was 90% in the slow (<0.83 m/s), 95% in the middle (0.83–1.00 m/s), and 97% in the fast (>1.00 m/s) gait speed tertiles, and risk of hospitalization was 45%, 33%, and 27%, respectively (both P<0.0001). After adjustment, gait speed remained predictive of mortality (hazard ratio, 2.16 per 0.1‐m/s decrease in gait speed; 95% confidence interval, 1.59–2.93) and rehospitalization (hazard ratio, 1.71 per 0.1‐m/s decrease in gait speed; 95% confidence interval, 1.45–2.0). In a landmark analysis, the effect of slow gait speed on mortality was most marked from 30 to 365 days after surgery, where each decline in 0.1 m/s of gait speed conferred a 2‐fold increased risk of mortality.

Conclusions

Gait speed is a simple tool to screen for frailty and identify older adults at risk for adverse events in the early and midterm postoperative periods.

Current Key Issues in Transcatheter Aortic Valve Replacement Undergoing a Paradigm Shift

As a new technology in the management of valvular heart disease, transcatheter aortic valve replacement (TAVR) has drawn much attention since its emergence. To date, numerous studies have investigated the safety and efficacy of TAVR in patients of various risk profiles with severe aortic stenosis (AS) and demonstrated comparable or superior outcomes of TAVR when compared with surgical aortic valve replacement (SAVR). The favorable outcomes of TAVR in inoperable patients, as well as in high- and intermediate-risk patients, are endorsed in current guidelines, and trials of low-risk patients have shown non-inferior or even superior results of TAVR than for SAVR, suggesting that the clinical indications of TAVR can be expanded to low-risk patients. Moreover, a therapeutic role of TAVR has been suggested in various aortic valve (AV) diseases, such as bicuspid AV, moderate AS with heart failure, aortic regurgitation, and bioprosthetic valve failure. In this review, we summarize the current issues of TAVR in various patient populations and discuss the expanding clinical indications of TAVR, which are driving a major paradigm shift in the management of AV disease.

Nutritional risk index is a better predictor of early mortality than conventional nutritional markers after transcatheter aortic valve replacement: A prospective cohort study

BACKGROUND

Nutritional risk index (NRI) has been shown to better predict survival than body mass index (BMI) or albumin after several cardiovascular interventions. Under assessment herein is whether NRI can have higher predictive value than conventional parameters for short-term survival after transcatheter aortic valve replacement (TAVR).

METHODS

A prospective cohort study was performed. In-hospital, 1-month and 3-month survival was evaluated. Since most patients undergoing TAVR are over 65, the NRI definition for a geriatric population (GNRI) was used. The impact of baseline BMI, albumin levels, and GNRI on in-hospital and short-term survival was assessed.

RESULTS

One hundred fifty two patients aged 82 ± 5.4 were included. In-hospital, 1-month, and 3-month mortality was 5.3%, 5.9%, and 9.2%, respectively. Mean GNRI was 112.7 ± 11.9, and was significantly lower in patients who died in-hospital (101.0 ± 8.8 vs. 113.3 ± 11.7), at 30 days (103.4 ± 10.9 vs. 113.3 ± 11.7), and at 90 days (104.0 ± 9.6 vs. 113.6 ± 11.8) than in survivors (all, p < 0.05). Three-month mortality in patients with no nutritional risk was 6.8% (9/132) vs. 25% (5/20) in patients with malnutrition (p = 0.022). In univariate analysis, GNRI predicted in-hospital, 30-day, and 90-day mortality (all, p < 0.05). Predictive value remained significant after adjusting for age, EuroSCORE II, and STS-Score (p < 0.05). Based on receiver operating curves, GNRI (AUC: 0.73) showed a better discrimination for 3-month mortality than albumin (0.69), weight (0.67) or BMI (0.62). The optimal cut-off value was 109.8.

CONCLUSIONS

The geriatric nutritional risk index predicts short-term mortality after TAVR and has a higher discriminating ability than other commonly used nutritional variables. It is a simple parameter that identifies those patients who could benefit from pre-procedural nutritional therapy.

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

BACKGROUND

Various frailty markers have been developed to guide better patient selection for transcatheter aortic valve implantation (TAVI). This study aimed to investigate the frequency and specific causes of unplanned hospital readmission after TAVI, and to investigate which frailty markers better predicted outcomes.

METHODS AND RESULTS

We retrospectively reviewed 155 patients for whom we calculated their Short Physical-Performance Battery (SPPB), Placement of AoRTic TraNscathetER Valve (PARTNER) frailty scale, frailty index, clinical frailty scale, modified Fried scale, and gait speed. The primary endpoint was unplanned readmission following TAVI. The clinical model was established using variables that were identified as independent predictors in multivariate analysis. Incremental values were assessed after adding each frailty marker to the clinical model, and were compared between frailty markers. Although unplanned readmission <30 days was 1.9%, 23% of patients had an unplanned readmission following TAVI mainly because of heart failure and pneumonia within 1 year. Frailty markers other than the modified Fried scale were independently associated with unplanned readmission. The SPPB and the PARTNER frailty scale significantly increased discriminatory performance for predicting unplanned readmission.

CONCLUSIONS

Unplanned readmissions following TAVI in the present study were fewer than previously reported. There seems to be a difference between frailty markers in their predictive performance. Precise frailty assessment may result in reducing unplanned admissions after TAVI and therefore better quality of life.

Computed tomography-based fat and muscle characteristics are associated with mortality after transcatheter aortic valve replacement

BACKGROUND

Computed tomography (CT)-based fat and muscle measures are associated with outcome in large populations. We tested if muscle and fat characteristics are associated with long-term outcomes after TAVR.

METHODS

We included 403 clinical CTs performed prior to TAVR at our center between 2008 and 2016, measuring area (cm2) and density (Hounsfield units, HU) of both psoas muscles (PM), subcutaneous adipose (SAT), and visceral adipose tissue (VAT). Area measures were indexed to height, log-transformed and both area and density were standardized for analysis. We assessed the association of each measure with all-cause mortality (adjusted for age, sex, body mass index (BMI), and the Society of Thoracic Surgeons (STS) risk score.

RESULTS

Of the 403 individuals (83 ± 8 years; 52% female), 167 (41.4%) died during a median follow-up of 458 days (interquartile range IQR 297-840). Fat measures were feasible and rapid. Fat area was available in 242 (60%) patients with an adequate field of view. Individuals with the lowest PM area, SAT area or VAT area exhibited the highest hazard of mortality. In addition, greater SAT density was associated with a higher mortality hazard (adjusted HR per standard deviation increase in density = 1.35, 95%CI 1.10-1.67, P = 0.005).

CONCLUSION

Rapid CT-based tissue characterization is feasible in patients referred for TAVR. Decreased PM area and increased SAT density are associated with long-term mortality after TAVR, even after accounting for age, sex, BMI, and STS score. Further studies are necessary to interrogate sex-specific relationships between CT tissue metrics and mortality and whether CT measures are incremental to well-established frailty metrics.