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

Sarcopenia and adipose tissue evaluation by artificial intelligence predicts the overall survival after TAVI

Sarcopenia is a serious systemic disease that reduces overall survival. TAVI is selectively performed in patients with severe aortic stenosis who are not indicated for open cardiac surgery due to severe polymorbidity. Artificial intelligence-assisted body composition assessment from available CT scans appears to be a simple tool to stratify these patients into low and high risk based on future estimates of all-cause mortality. Within our study, the segmentation of preprocedural CT scans at the level of the lumbar third vertebra in patients undergoing TAVI was performed using a neural network (AutoMATiCA). The obtained parameters (area and density of skeletal muscles and intramuscular, visceral, and subcutaneous adipose tissue) were analyzed using Cox univariate and multivariable models for continuous and categorical variables to assess the relation of selected variables with all-cause mortality. 866 patients were included (median(interquartile range)): age 79.7 (74.9-83.3) years; BMI 28.9 (25.9-32.6) kg/m2. Survival analysis was performed on all automatically obtained parameters of muscle and fat density and area. Skeletal muscle index (SMI in cm2/m2), visceral (VAT in HU) and subcutaneous adipose tissue (SAT in HU) density predicted the all-cause mortality in patients after TAVI expressed as hazard ratio (HR) with 95% confidence interval (CI): SMI HR 0.986, 95% CI (0.975-0.996); VAT 1.015 (1.002-1.028) and SAT 1.014 (1.004-1.023), all p < 0.05. Automatic body composition assessment can estimate higher all-cause mortality risk in patients after TAVI, which may be useful in preoperative clinical reasoning and stratification of patients.

Prognostic value of sarcopenia in older adults with transcatheter aortic valve implantation: A systematic review and meta-analysis

OBJECTIVE

We conducted this systematic review and meta-analysis to summarize the prevalence of sarcopenia and its impact on mortality in patients undergoing TAVI.

METHOD

Medline, EMBASE, and PubMed were searched from inception to October 14, 2022 to retrieve eligible studies that assessed sarcopenia in patients undergoing TAVI. Pooled sarcopenia prevalence was calculated with 95% confidence interval (CI), and heterogeneity was estimated using the I2 test. Associations of sarcopenia with mortality of post-TAVI were expressed as hazard ratio (HR) or odds ratios (OR) and 95% CI.

RESULTS

13 studies involving 5248 patients (mean age from 78.1 to 84.9 years) undergoing TAVI were included. There were eleven studies defined sarcopenia based on loss of skeletal muscle mass index (SMI), while only two studies used low muscle mass plus low muscle strength and/or low physical performance. Overall, the pooled prevalence of sarcopenia in patients undergoing TAVI was 49% (95% CI 41%-58%). Sarcopenia was associated with an increased risk of long-term (≥1 year) mortality in patients after TAVI (HR 1.57, 95% CI 1.33-1.85, P < 0.001), with similar findings in the subgroups stratified by follow-up time, definition of sarcopenia, study location, and study design. Furthermore, the 1-, 2-, and 3-year cumulative probabilities of survival in patients with sarcopenia were significantly lower than non-sarcopenia (74.0% vs 91.0%, 68.3% vs 78.0%, and 72.6% vs 79.8%, all P < 0.05).

CONCLUSIONS

Although there are substantial differences in diagnostic criteria, sarcopenia is highly prevalent in patients undergoing TAVI and its linked to increased long-term mortality after TAVI.

Prognostic Impact of Psoas Muscle Mass Index following Trans-Catheter Aortic Valve Replacement

BACKGROUND

Psoas muscle mass is a recently featured index of sarcopenia, which has a negative prognostic impact in patients with a variety of diseases. We investigated the prognostic impact of baseline psoas muscle mass in patients receiving a trans-catheter aortic valve replacement (TAVR).

METHODS

Patients who received TAVR at our center between 2015 and 2022 were included. Patients received computer tomography imaging upon admission as an institutional protocol, and psoas muscle mass was measured, which was indexed by body surface area. Patients were followed for four years or until January 2023. The prognostic impact of psoas muscle mass index on 4-year mortality following index discharge was evaluated.

RESULTS

A total of 322 patients (85 years, 95 male) were included. Median psoas muscle mass index at baseline was 10.9 (9.0, 13.5) × 10 cm³/m². A lower psoas muscle mass index tended to be associated with several index of malnutrition and sarcopenia. A psoas muscle mass index was independently associated with 4-year mortality with an adjusted hazard ratio of 0.88 (95% confidence interval 0.79-0.99, p = 0.044). Patients with lower psoas muscle mass index (below the statistically calculated cutoff of 10.7 × 10 cm³/m², N = 152) had significantly higher cumulative 4-year mortality compared with others (32% versus 13%, p = 0.008).

CONCLUSIONS

A lower psoas muscle mass index, which is a recently featured objective marker of sarcopenia, was associated with mid-term mortality following TAVR in the elderly cohort with severe aortic stenosis. The measurement of psoas muscle mass index prior to TAVR could have clinical implications for shared decision-making among patients, their relatives, and clinicians.

Preprocedural muscle strength and physical performance and the association with functional decline or mortality in frail older patients after transcatheter aortic valve implementation: a systematic review and meta-analysis

BACKGROUND

A significant number of older patients planned for transcatheter aortic valve implantation (TAVI) experience a decline in physical functioning and death, despite a successful procedure.

OBJECTIVE

To systematically review the literature on the association of preprocedural muscle strength and physical performance with functional decline or long-term mortality after TAVI.

METHODS

We followed the PRISMA guidelines and pre-registered this review at PROSPERO (CRD42020208032). A systematic search was conducted in MEDLINE and EMBASE from inception to 10 December 2021. Studies reporting on the association of preprocedural muscle strength or physical performance with functional decline or long-term (>6 months) mortality after the TAVI procedure were included. For outcomes reported by three or more studies, a meta-analysis was performed.

RESULTS

In total, two studies reporting on functional decline and 29 studies reporting on mortality were included. The association with functional decline was inconclusive. For mortality, meta-analysis showed that low handgrip strength (hazard ratio (HR) 1.80 [95% confidence interval (CI): 1.22-2.63]), lower distance on the 6-minute walk test (HR 1.15 [95% CI: 1.09-1.21] per 50 m decrease), low performance on the timed up and go test (>20 s) (HR 2.77 [95% CI: 1.79-4.30]) and slow gait speed (<0.83 m/s) (HR 2.24 [95% CI: 1.32-3.81]) were associated with higher long-term mortality.

CONCLUSIONS

Low muscle strength and physical performance are associated with higher mortality after TAVI, while the association with functional decline stays inconclusive. Future research should focus on interventions to increase muscle strength and physical performance in older cardiac patients.