Futility in Transcatheter Aortic Valve Implantation: A Search for Clarity

Abstract

Although transcatheter aortic valve implantation (TAVI) has revolutionised the landscape of treatment for aortic stenosis, there exists a cohort of patients where TAVI is deemed futile. Among the pivotal high-risk trials, one-third to half of patients either died or received no symptomatic benefit from the procedure at 1 year. Futility of TAVI results in the unnecessary exposure of risk for patients and inefficient resource utilisation for healthcare services. Several cardiac and extra-cardiac conditions and frailty increase the risk of mortality despite TAVI. Among the survivors, these comorbidities can inhibit improvements in symptoms and quality of life. However, certain conditions are reversible with TAVI (e.g. functional mitral regurgitation), attenuating the risk and improving outcomes. Quantification of disease severity, identification of reversible factors and a systematic evaluation of frailty can substantially improve risk stratification and outcomes. This review examines the contribution of pre-existing comorbidities towards futility in TAVI and suggests a systematic approach to guide patient evaluation.

The Positive Impact of Early Frailty Levels on Mortality in Elderly Patients with Severe Aortic Stenosis Undergoing Transcatheter/Surgical Aortic Valve Replacement

“…Our data suggest that in elderly patients affected by degenerative aortic valve disease, better surveillance, making use of integrated frailty assessment, may be desirable during valve cardiologic controls for surgical scheduling. This clinical path, which quantifies the contribution of clinical, surgical, and geriatric risk factors, may identify a new "favorable time window" in which the interventional treatment of AS may be appropriate to interrupt the progression of valve disease, heart failure, and frailty syndrome [40] and reduce the risk of futility [18]. More and larger clinical studies using frailty markers linked with a higher mortality risk after aortic valve interventional procedures are required.…”

“…[12][13][14][15]; thus, a comprehensive frailty assessment prior to TAVR could be a strategic approach in clinical decision making for the tailored management of patients with AS, an approach that could improve patient outcomes. The quantification of clinical features and functional levels may be useful in measuring reversible conditions in which TAVR could improve patient outcomes [14,[16][17][18].…”

An Update on Anti-thrombotic Therapy Following Transcatheter Aortic Valve Implantation: Expert Cardiologist Opinion from a UK and Ireland Delphi Group

“…The panel agreed that existing risk scores should be used with caution in TAVI patients who are in sinus rhythm. 23 Given the absence of risk scores designed for (or validated in) the TAVI population, there would be potential value in developing a risk-scoring system informed by contemporary clinical evidence. To address this evidence gap, further research is required to modify existing tools or develop de novo post-TAVI risk scores.…”

Acute Sarcopenia after Elective and Emergency Surgery

“…Such decision making is now often influenced by the findings of novel predictive risk factors, such as sarcopenia and frailty, associated with invasive surgical intervention. This has led to less invasive procedures being offered to those with frailty, and even the avoidance of all intervention altogether in cases of extreme frailty [ 71 ].…”