Malnourished patients have a three-fold risk of mortality after aortic valve replacement

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New data from the FRAILTY-AVR study indicate that mortality—both at 30 days and at one year—is significantly increased in malnourished patients undergoing aortic valve replacement. Furthermore, it shows that the risk of mortality associated with malnutrition is independent of the frailty status of the patient. These findings raise the question of whether pre and postoperative interventions to improve nutritional status should be considered in malnourished patients undergoing aortic valve replacement.

Writing in Circulation, Michael Goldfarb (Azrieli Heart Centre, Jewish General Hospital, McGill University, Montreal, Canada) and others report that malnutrition is a known risk factor for mortality in patients undergoing general surgery but add that its effect on patients undergoing cardiac surgery, including surgical aortic valve replacement, is less well known. “Among patients undergoing transcatheter aortic valve implantation (TAVI)—a population with high degrees of frailty—malnutrition has yet to be specifically studied,” they note.

Therefore, the aim of their study was to assess the prevalence and prognostic association between malnutrition screening (using the Mini Nutritional Assessment-Short Form [MNA-SF] score) and short and mid-term outcomes in a large multicentre study of older adults undergoing TAVI or surgical aortic valve replacement. The primary endpoint was one-year all-cause mortality.

Using data from FRAILTY-AVR (a prospective cohort study), Goldfarb et al found that 101 patients (8.7%) of 1,158 overall (of whom, 727 underwent TAVI) were malnourished; a further 380 (32.8%) were at risk of becoming malnourished. They comment: “Patients in the malnourished group were older, more likely to be female, more likely to undergo TAVI, more likely to have prior stroke, chronic kidney disease, chronic lung disease, anaemia, lower left ventricular ejection fraction, and higher STS-PROM.”

Jonathan Afilalo

In a multivariate analysis, preprocedural nutritional status was a significant predictor of one-year mortality (odds ratio [OR] 1.07 per MNA-SF point) and for 30-day composite safety events (OR 1.06 per MNA-SF point). The authors observe that while they expected there to be an overlap between patients who were malnourished and those who were frail, the correlation was actually modest. They explain, in terms of frailty, malnourished patients fell into distinct groups: those with mildly impaired frailty scores and those with severely impaired frailty scores. “The combination of malnutrition and severe frailty was synergistically associated with the highest risk of mortality,” Goldfarb et al state.

Noting that nutritional deficiencies are actionable and malnutrition is potentially a modifiable target, the authors say that their findings raises “the question of whether pre and postoperative intervention should be recommended in malnourished cardiac patients to improve postoperative outcomes”. They conclude: “Clinical trials are needed to validate the beneficial clinical impact of targeted nutritional interventions in malnourished or at-risk older adults undergoing TAVI or surgical aortic valve replacement.”

Study author Jonathan Afilalo (Azrieli Heart Centre, Jewish General Hospital, McGill University, Montreal, Canada) told Cardiovascular News: “Nutritional screening is vital for older adults undergoing cardiac surgery and TAVI; and if a patient is malnourished or at risk of becoming malnourished, consultation with a dietician and protein-rich oral nutritional supplements should be considered.”

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