Age alone should not preclude TAVI in patients aged ≥90 years

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The clinical frailty score currently used to assess suitability for transcatheter aortic valve implantation (TAVI) requires further refinement, a study published in the American Journal of Cardiology has concluded. However, the investigators also say that patients aged ≥90 years should not be refused TAVI based on their age alone, and that carefully selected patients “have excellent short- and mid-term outcomes post-TAVI”.

Julia Stehli, Antony Walton (Department of Cardiology, Alfred Hospital, Melbourne, Australia, and Cardiovascular Institute, Epworth Healthcare, Melbourne, Australia) et al evaluated short- and mid-term outcomes of nonagenarians following TAVI to address the lack of data available for these patients.

The prospective study was undertaken in two centres in Australia between 2008 and 2017, and all patients who underwent TAVI at the centres were included in a registry and followed-up for five years. Outcomes were based on Valve Academic Research Consortium-2 (VARC-2) criteria, and patients’ reliance on daily living support at one year was also evaluated. In all, 588 participants were included, with 71 (12.1%) aged ≥90 years (mean age 92.2±2 vs. 83.2±6 years in those <90 years old); the median Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) score was 5.7 in those ≥90 years compared to 3.9 in patients aged <90 years (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.01–1.13, p=0.02) and the median clinical frailty score for both groups was 4 (OR 0.88, p=0.44).

Stehli, Walton, et al found that mortality at 30 days was 0% in patients ≥90 years and 1.4% in patients <90 years (p=0.82); at one year it was 12% vs. 7.4%, respectively, for patients ≥90 years and <90 years (hazard ratio [HR] 1.64, p=0.20). There were no significant differences in periprocedural complications and mortality at five years between the two groups.

The authors also found that at one year, nonagenarians were significantly more likely to live in an aged-care facility compared to those <90 years (25% vs. 16%, OR 5.99, 95% CI 2.62–13.67, p<0.001). They conclude that as carefully selected older patients can experience positive benefits, age alone should not preclude them from treatment. But, they say: “The significantly higher rate of transfer to an aged-care facility highlights the importance of a more refined frailty assessment prior to TAVI.”

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