Comparison of Outcomes of Transfemoral Aortic Valve Implantation in Patients <90 With Those >90 Years of Age

https://doi.org/10.1016/j.amjcard.2018.02.056Get rights and content

In patients who underwent transcatheter aortic valve implantation (TAVI), postoperative mortality risk is commonly assessed with risk scores such as the Society of Thoracic Surgeons—Postoperative Risk of Mortality (STS-PROM) and EuroSCORE II, in which age plays a dominant role. However, we reason that in the naturally selected oldest-old patients (nonagenarians), this may not be completely justified and that therefore age should play a minor role in decision-making. The objective of this study was to compare procedural outcome and mid-term mortality of transfemoral (TF)-TAVI patients aged ≥90 years with patients aged <90 years. In this single-center analysis of 599 prospectively acquired consecutive TF-TAVI patients between 2009 and 2017, we compared patients aged ≥90 (i.e., nonagenarians, n = 47) with patients aged <90 years (n = 552), using Kaplan-Meyer analysis and multivariate logistic regression. In the nonagenarians, we found more aortic regurgitation, moderate to severe paravalvular leakage, strokes and vascular complications, and less device success and bleeding complications compared with patients <90 years. Both groups showed similar symptomatic improvement. The predicted (STS-PROM) and actual procedural mortality were 8.033% and 2.1% (3.8×) and 4.868% and 1.8% (2.7×) for the nonagenarians and controls, respectively. Survival was not statistically different at the 1-, 2-, 3-, 4-, and 5-year mark. In conclusion, nonagenarians had similar symptomatic improvement and acceptable procedural outcome and mid-term survival to TF-TAVI patients aged <90 years. Thus, age is not a risk factor in predicting postoperative outcome and mortality and therefore should not be a reason to deny the oldest-old patient transfemoral TAVI.

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Methods

The Ethics Committee of the Academic Medical Centre (AMC) Amsterdam, the Netherlands, approved this research with a waiver. The population comprised all consecutive patients who underwent a transfemoral (TF)-TAVI with a balloon-expandable SAPIEN XT or SAPIEN 3 prosthesis (Edwards Lifesciences, Irvine, CA), between January 8, 2009, and February 28, 2017, in the AMC. The decision for TAVI treatment was made by our multidisciplinary TAVI team consisting of a cardiologist, a cardiac surgeon, a

Results

A total of 599 patients underwent TF-TAVI with the SAPIEN XT of SAPIEN 3. Of these patients 47 (8%) were nonagenarians (Table 1). There were relatively more females in the nonagenarian group and they had fewer risk factors (diabetes, smoking, declined renal function) and fewer co-morbidities (less previous coronary artery bypass, previous strokes, chronic obstructive pulmonary disease). Nonagenarians had a higher mean estimated postoperative mortality compared with the controls. Of the 47

Discussion

Our study shows that nonagenarian patients have very acceptable procedural and mid-term results compared with younger controls, when treated with TF-TAVI. Several earlier studies have shown that TAVI is feasible and safe in nonagenarians,6, 8, 16, 17, 18, 19 a finding that we have confirmed in our study. In the current literature, 30-day mortality varies from 3.2% to 12.0%, depending on the access route used. We found an even lower 30-day mortality of 2.1% in our patients who were treated

Disclosures

Dr. Baan receives an unrestricted research grant from Edwards Lifesciences and is a proctor for Edwards Lifesciences.

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The first affiliation is part of the Amsterdam Cardiovascular Sciences.

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