Comparison of Outcomes of Transcatheter Aortic Valve Implantation in Patients ≥90 Years Versus <90 Years

doi:10.1016/j.amjcard.2015.06.033

The American Journal of Cardiology

Volume 116, Issue 7, 1 October 2015, Pages 1110-1115

https://doi.org/10.1016/j.amjcard.2015.06.033 Get rights and content

Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) is increasingly performed in nonagenarians. There is scarce evidence on the feasibility and safety of balloon-expandable TAVI in this patient population. A total of 734 patients who underwent balloon-expandable TAVI at our institute were included in the study. We compared 136 patients who were aged at least 90 years at the time of TAVI (mean age 92.4 ± 2.4 years) with the remaining 598 younger patients (mean age 79.7 ± 7.8 years). Valve Academic Research Consortium 2 end points were compared between the 2 groups. Diabetes mellitus, coronary artery disease (CAD), peripheral artery disease (PAD), and chronic lung disease were significantly less prevalent in patients aged ≥90 years. In contrast, the prevalence of frailty, chronic renal failure, and atrial fibrillation was significantly higher in these patients. Device success was 96% in both groups. All-cause mortality at 30 days and 1 year was 2.9% and 12.5% versus 2.8% and 12.3% in patients aged ≥90 and <90, respectively (p = 0.95 for both). All major complication rates were similar between groups. Nonagenarians had higher rates of minor vascular complications (13.2% vs 7.7%; p = 0.04). In conclusion, performing balloon-expandable TAVI in carefully selected group of nonagenarians is feasible and offers clinical benefit comparable to patients aged <90 years. Advanced age, in the absence of significant co-morbidities, should not deter clinicians from evaluating patients for TAVI for severe AS.

Section snippets

Methods

We examined consecutive high-risk patients with severe symptomatic AS who underwent balloon-expandable TAVI during a 3-year period at our institute. All patients had congestive heart failure with New York Heart Association (NYHA) class II to IV symptoms. All underwent preprocedural coronary angiography to assess the need of revascularization. Aortic valve disease was assessed initially with transthoracic echocardiography followed by an electrocardiographic-gated, multislice CT angiography

Results

From April 2012 to December 2014, 734 patients underwent balloon-expandable TAVI (Edwards Lifesciences, Irvine, California), at our institute. From this cohort, 136 patients were aged at least 90 years at the time of TAVI (mean age 92.4 ± 2.4 years). The remaining 598 younger patients had a mean age of 79.7 ± 7.8 years. Transfemoral approach was used in 85.3% of the cases, transapical approach in 5.6%, transaortic approach in 8.3%, and subclavian approach in 0.8%. The baseline clinical,

Discussion

The results of the present study indicate that performing balloon-expandable TAVI in nonagenarians is feasible and safe. Nonagenarians were found to have several significantly different co-morbidities compared to younger patients. We found high device success rate in both age groups and similar 30-day and 1-year survival, short-term major complication rates, and NYHA functional capacity improvement. Nonagenarians had significantly higher rates of minor vascular complications.

Advanced age is a

Disclosures

Dr. Makkar has received grant support from Edwards Lifesciences Corporation and St. Jude Medical; is a consultant for Abbott Vascular, Cordis, and Medtronic; and holds equity in Entourage Medical. Dr. Jilaihawi is a consultant for Edwards Lifesciences Corporation, St. Jude Medical, and Venus MedTech. All other authors report no relationships that could be construed as a conflict of interest.

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Cited by (33)

Long-Term Survival and Quality of Life Following Transcatheter Aortic Valve Replacement in Nonagenarians
2024, American Journal of Cardiology
Transcatheter aortic valve replacement (TAVR) has emerged as a successful treatment option for severe aortic stenosis. However, the long-term outcomes of TAVR in nonagenarians is lacking. We aimed to examine the long-term mortality and quality of life in nonagenarians after TAVR. This is a multicenter, retrospective analysis on patients with severe aortic stenosis who underwent TAVR. Patients were divided into 2 groups: nonagenarians (age ≥90 years) and age <90 years. The Kansas City cardiomyopathy questionnaire (KCCQ) and New York Heart Association (NYHA) scores were compared before and after TAVR. All-cause mortality was compared between both groups at 30 days, 1 year, and 5 years after TAVR using the Cox proportional hazard model. A total of 6,896 patients were included, of whom 591 were nonagenarians. Nonagenarians had a higher Society of Thoracic Surgeons perioperative risk of mortality (8.1 ± 4.6% vs 5.4 ± 4.2%, p <0.001) before TAVR. Both groups were similar in KCCQ and NYHA scores at baseline. At 1 year after TAVR, there was no significant difference in improvement in the KCCQ overall score between those aged <90 years and nonagenarians (−4.76, 95% confidence interval [CI] −11.4 to 1.9, p = 0.161). Similarly, there was no statistically significant difference in improvement in NYHA class between the 2 groups at 1 year (odds ratio 1.07, 95% CI 0.85 to 1.25), p = 0.526). The unadjusted 30-day (3.2% vs 2.7%, hazard ratio 1.11, 95% CI 0.70 to 1.80, p = 0.667) and 5-year (28.0% vs 26.6%, hazard ratio 1.05, 95% CI 0.89 to 1.24, p = 0.60) all-cause mortality were similar between the 2 groups. In conclusion, this study demonstrates an excellent long-term mortality rate at 5 years after TAVR in nonagenarians, comparable to patients younger than 90 years. There is a significant and enduring improvement in functional status in nonagenarians, observed up to 1 year after TAVR.
Outcomes of Transcatheter Aortic Valve Implantation in Nonagenarians Compared to Younger than 90 Year Old Patients
2022, American Journal of Medicine
Citation Excerpt :
However, there are no statistical difference in the rate of procedural success, which reach up to 94% in nonagenarians and 97% in <90-year-old patients. These findings were also supported by results from previous cohorts.12-14 At the moment, nonagenarians constitute a significant proportion of the entire population, and the need for invasive cardiac approaches is expected to increase in people of extreme age.
Given that life expectancy has improved, nonagenarians have become a significant proportion of world population. As aortic stenosis is primarily a disease of the elderly, the need for invasive cardiac approaches is expected to increase in people of extreme age. Herein, we compare the in-hospital adverse clinical outcomes and mortality after transcatheter aortic valve implantation (TAVI) procedures in nonagenarians to younger than 90 year old patients.
A retrospective study was conducted on 1336 patients who underwent TAVI between January 2016 and March 2020 at Toulouse University Hospital, Rangueil, France. Post-TAVI adverse clinical outcomes were defined according to Valve Academic Research Consortium-2 Criteria. The studied population was divided into 2 groups according to age.
Out of 1336 patients, 250 (18.7%) were nonagenarians with a mean age of 91.8 ± 1.9 years. Pacemaker implantation (12.4% vs 12.1%), stroke (2% vs 1.8%), and major vascular complications (9.2% vs 6.7%) were more common in nonagenarians, whereas acute kidney injury (1.2% vs 2.7%) and major bleeding events (3.2% vs 3.4%) were more common in the <90-year-old group. Nonagenarians are more likely to develop major vascular complications (odds ratio [OR] = 1.76 95% confidence interval [CI] 1.04-3, P = .03). The prevalence of in-hospital mortality in nonagenarians and <90-year-old patients were 5.2% and 2%, respectively. Survival analysis showed a significant difference in mortality during hospitalization period only ( P = .04).
The prevalence of TAVI procedural success is remarkably high in nonagenarians and comparable to that of younger patients. However, the in-hospital mortality rate was 2-fold more than that of <90-year-old patients.
TAVR in nonagenarians: An analysis investigating safety, efficacy, symptomatic improvement, and long-term survival
2021, Journal of Cardiology
Citation Excerpt :
The authors showed a significantly higher 1-year mortality rate among older patients. 1-year survival reported in other studies including at least 80 nonagenarians ranged from 69.1% to 87.5% and was comparable to our analysis [4,11-13, 24]. Although our study is smaller, this study is the first to investigate 2-year survival in more than 150 nonagenarians, and more procedural endpoints were analyzed including devices success, acute kidney failure, and the need for pacemaker implantation.
In the aging western societies, an increasing prevalence of severe, symptomatic aortic stenosis is observed. The aim of this study was to examine the safety and efficacy of transcatheter aortic valve replacement (TAVR) in patients aged 90 years and older.
All patients with severe symptomatic aortic stenosis undergoing TAVR at LMU Munich-University-Hospital between 2013 and 2018 were included. Procedure-related mortality (<30 days) was defined as the primary endpoint and survival rates at two years, device failure, and procedural complications were defined as secondary endpoints according to the Valve Academic Research Consortium II criteria.
Out of 2336 patients, 2183 were younger than 90 years (<90y.-group) and 153 patients were aged 90 or older (≥90y.-group). Procedure-related mortality (3.6% <90y.-group vs. 3.3% ≥90y.-group, log-rank p=0.9) and device success (97.2% <90y.-group vs. 96.0% ≥90y.-group, p=0.44) were similar. Estimated survival rates at 2 years were 62.8% (95% CI 55.3 and 71.4) in the elder and 76.0% (95% CI 74.1 and 77.8) in the younger patients (p<0.01). The incidence of acute kidney injury, stroke, major bleeding, and permanent pacemaker implantations were comparable between both groups.
TAVR procedure is equally safe and feasible in patients aged 90 years or older compared to younger patients. Differences in 2-year survival appear to be patient-related rather than procedure-related.
Age-Related Outcomes After Transcatheter Aortic Valve Replacement: Insights From the SwissTAVI Registry
2021, JACC: Cardiovascular Interventions
The aim of this study was to investigate age-related outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) as assessed in a nationwide, prospective, multicenter cohort study.
TAVR is the preferred treatment for elderly patients with severe aortic stenosis and is expanding into lower age groups.
Data from the SwissTAVI Registry were analyzed. Clinical outcomes were compared between patients 70 years of age or younger (n = 324), 70 to 79 years of age (n = 1,913), 80 to 89 years of age (n = 4,353), and older than 90 years of age (n = 507). Observed deaths were correlated with expected deaths in the general Swiss population using standardized mortality ratios.
Between February 2011 and June 2018, 7,097 patients (mean age 82.0 ± 6.4 years, 49.6% women) underwent TAVR at 15 hospitals in Switzerland. Procedural characteristics were similar; however, older patients more often had discharge to the referring hospital or a rehabilitation facility after TAVR. Using adjusted analyses, a linear trend for mortality (30-day adjusted hazard ratio [HR_adj]: 1.45; 95% confidence interval [CI]: 1.18 to 1.77; 1-year HR_adj: 1.12; 95% CI: 1.01 to 1.24), cerebrovascular accidents (30-day HR_adj: 1.35; 95% CI: 1.09 to 1.66; 1-year HR_adj: 1.21; 95% CI: 1.02 to 1.45), and pacemaker implantation (30-day HR_adj: 1.23; 95% CI: 1.12 to 1.34; 1-year HR_adj: 1.19; 95% CI: 1.09 to 1.30) was observed with increasing age. Furthermore, standardized mortality ratios were 12.63 (95% CI: 9.06 to 17.58), 4.09 (95% CI: 3.56 to 4.74), 1.63 (95% CI: 1.50 to 1.78), and 0.93 (95% CI: 0.76 to 1.14) for TAVR patients in relation to the Swiss population <70, 70 to 79, 80 to 89 and ≥90 years of age, respectively.
Increasing age is associated with a linear trend for mortality, stroke, and pacemaker implantation during early and longer-term follow-up after TAVR. Standardized mortality ratios were higher for TAVR patients younger than 90 years of age compared with expected rates of mortality in an age- and sex-matched Swiss population. (SWISS TAVI Registry; NCT01368250)
Comparison of Outcomes of Transcatheter Aortic Valve Implantation in Patients Aged >90 Years Versus <90 Years
2019, American Journal of Cardiology
Citation Excerpt :
This observation may have translated into better outcomes for our nonagenarians compared with other nonagenarian cohorts. Further, our nonagenarian patients were referred later in the disease process, as evidenced by the higher average MPG than other nonagenarian cohorts (54 mm Hg vs 46 to 47 mm Hg),11,13,14,23 and compared with our own <90-year-old cohort (54 mm Hg vs 48 mm Hg), therefore undergoing a certain selection process before they are considered for TAVI. Previous studies have demonstrated the cost-effectiveness of TAVI, by keeping patients with severe symptomatic AS out of hospital and functioning independently in the community.25
Limited data exist regarding transcatheter aortic valve implantation (TAVI) in nonagenarians. This study evaluates the short- and mid-term outcomes of nonagenarians after TAVI. Between 2008 and 2017, all patients who underwent TAVI in 2 centers in Australia were prospectively included in a registry and followed-up for 5 years. Outcomes were based on VARC-2 criteria. Additionally, the patient's reliance on daily living support at 1 year was evaluated. Of the 588 patients, 71 (12.1%) were ≥90 years old (mean age 92.2 ± 2 vs 83.2 ± 6 years in <90-year-old patients), with a median STS-PROM score of 5.7 (vs 3.9 in <90-year-old patients, odds ratio [OR] 1.07, 95% confidence interval 1.01 to 1.13, p = 0.02) and a median clinical frailty score of 4 (vs 4 <90-year-old patients, OR 0.88, p = 0.44). Mortality was 0% in ≥90-year-old patients at 30 days (vs 1.4% in <90-year-old patients; p = 0.82) and 12% at 1 year (vs 7.4%, in <90-year-old patients; hazard ratio 1.64, p = 0.20). There were no significant differences in periprocedural complications and mortality at 5 years between the 2 groups. At 1 year, nonagenarians were significantly more likely to live in an aged-care facility compared with <90-year-old patients (25% vs 16%, OR 5.99, 95% confidence interval 2.62 to 13.67, p <0.001). In conclusion, carefully selected nonagenarians have excellent short- and mid-term outcomes post-TAVI and should therefore not be refused based on age alone. Nevertheless, the significantly higher rate of transfer to an aged-care facility highlights the importance of a more refined frailty assessment before TAVI than the currently widely used clinical frailty score.
Transcatheter Aortic Valve Implantation in Nonagenarians: Procedural Outcome and Mid-Term Results
2018, Heart Lung and Circulation
For nonagenarians with symptomatic severe aortic stenosis transcatheter aortic valve implantation (TAVI) has become a feasible therapeutic option. Therefore, the aim of this study was to evaluate the procedural outcomes and mid-term follow-up in this patient group and compare this to octogenarians.
From 1359 patients who underwent TAVI at our institution between March 2009 and February 2016, 82 patients were nonagenarians and 912 were octogenarians. In nonagenarians, mean age was 91.9 ± 1.4 years and compared to octogenarians showed a significantly higher logistic EuroScore (27.7 ± 14.8% vs. 23.1 ± 14.4, p = 0.005) and STS Score (8.5 ± 4.8% vs. 6.3 ± 6.7, p = 0.001).
There were no significant differences with regard to stroke rate, pacemaker implantation rate and major vascular complications between the two groups. Thirty-day mortality was 9.8% in nonagenarians and 4.1% in octogenarians (p = 0.04). At 1 year, all-cause mortality increased to 30.9% vs. 18.6% (n.s.).
Nonagenarians showed an increased periprocedural mortality during TAVI and higher mortality in follow-up compared to octogenarians. Age alone is not a predictive factor but indication for treatment should be carefully evaluated by the heart team on an individual basis.

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Valvular Heart DiseaseComparison of Outcomes of Transcatheter Aortic Valve Implantation in Patients ≥90 Years Versus <90 Years

Section snippets

Methods

Results

Discussion

Disclosures

J Am Coll Cardiol

J Am Coll Cardiol

JACC Cardiovasc Interv

Am J Cardiol

Am J Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Cardiol

Ann Thorac Surg

Am J Cardiol

Eur J Intern Med

J Am Coll Surg

J Thorac Cardiovasc Surg

Am J Cardiol

Valvular Heart Disease
Comparison of Outcomes of Transcatheter Aortic Valve Implantation in Patients ≥90 Years Versus <90 Years