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TAVR, surgical AVR confer functional decline in older patients with frailty
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Older patients with severe frailty who underwent transcatheter or surgical aortic valve replacement for aortic stenosis had an increased risk for functional decline or a lack of improvement after the procedure, according to a study published in JAMA Internal Medicine.
“Despite disease-specific benefits of TAVR and [surgical] AVR, functional decline or lack of improvement is common in older adults, particularly in those with severe frailty,” Dae Hyun Kim, MD, MPH, ScD, assistant professor of medicine in the department of pharmacoepidemiology and pharmacoeconomics at Brigham and Women’s Hospital, and colleagues wrote. “Anticipated functional trajectories after the procedure should inform patient-centered shared decision-making about these procedures and perioperative care to optimize functional outcomes.”
Patients with aortic stenosis
Researchers analyzed data from 246 patients with aortic stenosis who underwent TAVR (n = 143; mean age, 84 years; 52% women) or surgical AVR (n = 103; mean age, 78 years; 45% women). Patient interviews and medical records reviews were performed to collect information on NYHA class HF, demographic characteristics, echocardiographic data and cardiac, noncardiac and geriatric conditions. Other information that was collected and assessed included depressive symptoms, self-reported functional status, comprehensive geriatric assessment-based frailty index and postoperative complications such as MI, stroke, transient attack and bleeding. Higher values of the comprehensive geriatric assessment-based frailty index indicated greater frailty.
Telephone interviews were conducted at 1, 3, 6, 9 and 12 months to assess a patient’s ability to perform 22 physical tasks and daily activities.
Based on functional status at baseline and during follow-up, researchers identified five trajectories: from excellent at baseline to improvement at follow-up; good (high baseline to full recovery); fair (moderate baseline to minimal decline); poor (low baseline to moderate decline); and very poor (low baseline to large decline).
In patients after TAVR, the most common trajectory was fair (37.8%), followed by good (23.1%), poor (14.7%), excellent (14%) and very poor (8.4%). Common trajectories for patients after surgical AVR were good (37.9%), excellent (36.9%), fair (19.4%), poor (2.9%) and very poor (1%), the researchers reported.
Preoperative frailty level was linked to a greater probability of functional decline and a lower probability of functional improvement.
Frailty levels
Patients after TAVR who had a comprehensive geriatric assessment-based frailty index of 0.2 or lower had excellent (50%) or good trajectories (50%), although those with levels of 0.51 or higher had poor (45.5%) or very poor trajectories (22.7%). Those in the surgical AVR group who had an index of 0.2 or lower had excellent (58.5%) or good trajectories (36.6%), and those with levels between 0.41 and 0.5 had a fair trajectory (71.4%), according to the study.
Major complications and postoperative delirium were linked to functional decline after TAVR compared with those without complications (51.9% vs. 16.4%) or postoperative delirium (50% vs. 13.4%). A lack of improvement after surgical AVR was also seen in the presence of major complications (62.5% vs. 79.3%) and postoperative delirium (69.2% vs. 81.6%).
“For frail patients, interventions can be considered to optimize health status before the procedure,” Kim and colleagues wrote. “Clinical trials (NCT02219815, NCT02597985, NCT03107897) are underway to evaluate the benefit of prehabilitation in older adults undergoing cardiac surgery. Because major complications and delirium are associated with an unfavorable functional trajectory, efforts to reduce procedure-related complications and delirium through better surgical techniques or devices, safer anesthesia methods and prevention of delirium may improve functional outcomes.” – by Darlene Dobkowski
Disclosures: Kim reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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