Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile?

Abstract

A growing number of nonagenarians is recorded as life expectancy increases. Unfortunately, this extreme-aged group is plagued by increased prevalence of aortic stenosis amidst a higher occurrence of comorbidities that pose dilemmas to cardiologists and cardiac surgeons when having to choose a conservative or interventional treatment modality, and a surgical or transcatheter aortic valve implantation (TAVI) approach. TAVI is an expensive procedure, which also confers a higher mortality and morbidity risk in nonagenarians, compared to younger patients. Considering the physiologic rather the chronologic age alone, and adopting a shared-decision making approach (participatory medicine), it may be more realistic to determine a patient's candidacy for this non-surgical therapeutic modality. Thus, it comes down to the patient selection process by having the heart team review each nonagenarian case individually and getting the patient and the family involved, always aiming to prolong and improve patient's quality of life (QoL), but also taking into consideration patient preferences and values, sharing and respecting goals, realistic expectations, and end-of-life views and ideas. One should keep in mind that there is always the possibility that TAVI may be clinically futile for patients who have a multitude of comorbidities and extreme frailty, for whom a transition to palliative care might be prudent. Selecting nonagenarian patients with low comorbidity index and with no extreme frailty, adopting a minimalistic approach and paying attention to vascular access hemostasis may provide the elements that may lead to a successful, desirable and hopefully cost-effective outcome.

Clinical Outcomes of Transcatheter Aortic Valve Replacement in Nonagenarians: A Systematic Review and Meta-Analysis

“…Manolis et al demonstrated that, in nonagenarians who underwent TAVR, bleeding and vascular complications ranged from 9% to 34% (average 16%), and stroke risk ranged from 2% to 18% (average 3–4%) [25]. Similarly, in this meta-analysis, we indicated that nonagenarians were associated with significantly increased rates of major or life-threatening bleeding, vascular complications and stroke of 20%, 35%, and 32%, respectively.…”

Early and Long-Term Outcomes of Transcatheter Aortic Valve Replacement for Selected Nonagenarians in Japan

“…There are several reports regarding the outcomes of TAVI in nonagenarians from Western countries. 8- 10 Yokoyama et al investigated the clinical outcomes after TAVI among Japanese nonagenarians. 11 They reported that early safety and 3-year mortality in nonagenarians were similar to those in patients aged <90 years.…”

Transcatheter aortic valve implantation in nonagenarians – old…but not obsolete!

“…Chronological age alone should not deprive patients of treatment -it is the physiological age that should determine a patient's candidacy for treatment of aortic valve stenosis. The aim of TAVI in this age group is primarily to make the patient feel better and to increase their quality of life but not necessarily to help them to live longer 3,4 .…”

“…Selecting nonagenarian patients with a low comorbidity index and no extreme frailty, adopting a minimalistic approach, and paying attention to vascular access haemostasis may provide the elements that lead to a successful, desirable, and hopefully cost-effective outcome. Finally, quality-of-life studies are direly needed and eagerly awaited in this patient subpopulation in order to provide guidance on the patient selection process 3,4 .…”