Early Safety and Efficacy of Transcatheter Aortic Valve Implantation for Asian Nonagenarians (from KMH Registry)

Abstract

SummaryAs Japan has one of the most rapidly aging populations in the world, transcatheter aortic valve implantation (TAVI) is likely to be performed in increasing numbers of older people. There is little information on either the efficacy or the safety of TAVI in nonagenarians in Asia.From October 2013 to June 2015, 112 consecutive patients underwent TAVI with Edwards SAPIEN XT valves in our institution. We compared 25 patients aged at least 90 years (mean 91.6 ± 1.7 years) with 87 patients aged under 90 years (mean 82.5 ± 6.0 years) at the time of TAVI. All definitions of clinical endpoints and adverse events were based on the Valve Academic Research Consortium 2 definitions.The median follow-up interval was 561.5 days (the first and third quarters, 405.0 and 735.8 days). Nonagenarians had a higher logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), Euro II score, and the Society of Thoracic Surgeons predictive risk of mortality (STS) score, and a prevalence of clinical frailty scale !4. The rate of device success, and the 30-day and 6-month mortalities were not different between patients aged !90 years and < 90 years (96.0% versus 92.0%, P = 0.68; both 0%, P = 1.00; 4.0% versus 3.5%, P = 0.32, respectively). At six months, clinical efficacy and time-related valve safety were also similar in the two groups (12.5% versus 13.4%, P = 1.00; 4.5% versus 10.3%, P = 0.68, respectively). The cumulative 1-year mortalities were not significantly different between the two groups (8.4% versus 9.4%, P = 0.94, respectively).TAVI can contribute to acceptable clinical results and benefits in a carefully selected group of nonagenarians in Asia.(Int Heart J 2017; 58: 900-907)

Transcatheter aortic valve replacement over age 90: Risks vs benefits

“…Frailty has been said to be a better indicator of biological aging and accumulated deficits. Nine studies measured frailty by at least one objective metric such as the Clinical Frailty Scale or the 5‐m gait speed test . Frailty was consistently found to be predictive of mortality and major morbidity after adjusting for comorbid conditions and cardiac status.…”

“…In a sub‐study from the FRAILTY‐AVR study, nonfemoral access was associated with higher 30‐day mortality in frail patients (odds ratio 3.91, 95% CI 1.48 to 10.31) whereas this was not the case in robust patients (OR 1.29, 95% CI 0.34 to 4.94) . While this comparison of femoral and nonfemoral access routes is clearly not randomized, most sources support the notion of higher risks in nonfemoral TAVR and favor femoral TAVR in older patients whenever possible.…”

“…Interestingly, this 1‐year mortality is not drastically different than that of nonagenarians in the general population, which is approximately 15%. In studies comparing patients above and below age 90, the risk of mortality was slightly increased in some studies and no different in others . This inconsistency is at least partially attributable to variable adjustment for age‐related confounders.…”

“…Nonagenarians undergoing TAVR are more likely to be women, which is not surprising considering that nonagenarian women outnumber nonagenarian men by 3‐to‐1 in the general population. Nonagenarians undergoing TAVR are less likely to present with comorbid coronary artery disease, peripheral arterial disease, diabetes mellitus, and multiple chronic conditions . These differences can be explained by the healthy survivor effect, the clinician's cognitive bias to be conservative in nonagenarians with significant comorbidities, or a combination of the two.…”

“…Nonagenarians undergoing TAVR are less likely to present with comorbid coronary artery disease, peripheral arterial disease, diabetes mellitus, and multiple chronic conditions. 10,21,24,[27][28][29][30][31][32][33] These differences can be explained by the healthy survivor effect, the clinician's cognitive bias to be conservative in nonagenarians with significant comorbidities, or a combination of the two.…”