TAVI in the elderly person: how far to go? Patrick Friocourt Ple - - PowerPoint PPT Presentation

TAVI in the elderly person: how far to go?

Patrick Friocourt Pôle autonomie, CH Blois

JESFC 2017

Aortic stenosis

• 2 - 7% of the population > 65 years*
• Duration of the asymptomatic phase varies widely between

individuals*

• As soon as symptoms occur, the prognosis of severe AS is

dismal, with survival rates of only 15–50% at 5 years*

*Guidelines ESC

Recommendations for the use of transcatheter aortic valve implantation

• TAVI is indicated in patients

– with severe symptomatic AS who are not suitable for AVR as assessed by a ‘heart team’ and – who are likely to gain improvement in their quality of life (Class 1, Level B) – and to have a life expectancy of more than 1 year after consideration of their comorbidities (Class 1, Level B)

ESC Guidelines European Heart Journal (2012) 33, 2451–2496

Recommendations for the use of transcatheter aortic valve implantation

• Some contraindications* :

– Appropriateness of TAVI, as an alternative to AVR, not confirmed by a ‘heart team’

– Clinical

• Estimated life expectancy <1 year
• Improvement of quality of life by TAVI unlikely because of

comorbidities

• Severe primary associated disease of other valves with

major contribution to the patient’s symptoms, that can be treated only by surgery

*ESC Guidelines European Heart Journal (2012) 33, 2451–2496

Is age a contraindication for use of TAVI?

• « Age is a priori a contraindication » = Ageism !
• Life expectancy?

http://www.opale-bg.fr/esperance-de-vie Calculator : see « calculis.net/esperance-de-vie » Healthy Life Years (HLY) ….

TAVI patients ≥ 90 years

• ≥ 90 vs < 90 y (136-598 pts, 92.4 vs 79.7 years)
• Comorbidities less prevalent: Diabetes mellitus,

coronary artery disease (CAD), peripheral artery disease (PAD), and chronic lung disease

• More prevalent: frailty, chronic renal failure, and

atrial fibrillation

• Mortality after TAVI

30 days 1 year 12.5 vs 2.9% 12.5 vs 12.3%

• Advanced age, in the absence of significant

comorbidities, should not deter clinicians from evaluating patients for TAVI for severe AS

Abramowitz Am J Cardiol 2015;116:1110e 1115

Define poor outcome ?

• Poor outcome 6 monts after TAVR

– Death – Poor quality of life – Substantial worsening of quality of life

• Death or KCCQ < 45 or KCCQ decrease ≥ 10

points

• Death or KCCQ decrease ≥ 10 points or KCCQ <

45 (unless KCCQ increases by ≥ 10 points)

Arnold Circ Cardiovasc Qual Outcome 2013; 6:591-597 KCCQ : Kansas City Cardiomyopathy Questionnaire

Comorbidities and aortic stenosis

Non cardiac comorbidities

• Chronic kidney disease (eGFR<60 ml/min/1.73

m2 53.7%

• Hypertension

82.9%

• Hypercholesterolemia

60%

– Statin 53.3%

• COPD

25.4%

• Diabetes

30%

• Anemia

48.75%

– < 10 g/dl 13.2%

• Cerebrovascular disease

30.8%

– Previous stroke 7% – Carotid atherosclerosis 23.7%

• Peripheral artery disease

11.6%

• Abdominal aortic aneuvrysm

4.6%

• Cancer

26.6%

– New diagnosis 5.4% – Previous 21;2%

Associated cardiac disease

• Coronary ischemic disease

43.7%

– Previous AMI 17.5%

– Previous PCI/CABG 28.3%

• LVMI (g/m2)

204.5±60.46 LVMI >125 g/m2 93%

• FEVG ≤50%

28.7%

– Severe EF < 30% 6.2%

• Pulmonary hypertension

67%

– Severe sPAP > 60 mm Hg 8.3%

• Aortic regurgitation

17%

• Atrial fibrillation

35.4%

• Pace-maker

18.3%

• Left bundle branch block

12.5% Faggiano International Journal of Cardiology 159 (2012) 94–99

TAVI : predictors of increased risk

Clinical predictors

• Severely reduced left ventricular function
• Very low transvalvular gradient (mean

gradient <20 mm Hg)

• Low flow (low stroke volume index, <35

ml/m2)

• Severe myocardial fibrosis
• Severe concomitant mitral and/or

tricuspid valve disease

• Severe pulmonary hypertension (PASP !60

mm Hg)

• Severe lung disease, particularly oxygen-

dependent

• Advanced renal impairment (stages 4 and

5)

• Liver disease
• Very high STS score (predicted risk of

mortality >15%)

Geriatric predictors

• Advanced frailty
• Disability in activities of daily living
• Malnutrition
• Mobility impairment
• Low muscle mass and strength

(“sarcopenia”)

• Cognitive impairment
• Mood disorders (depression, anxiety)

Lindman JACC interventions 2014; 7, 7 : 707-716

Frailty & cardiac surgery

• Retrospective survey 3.826 cardiac surgery pts,
• 3.669 nonfrail patients mean age 66 y (15-94), 157 frail patients

mean age 71 y (18-88)

• Frailty : impairment ADL (Katz index), some

dependence in ambulation, previous diagnosis of dementia

• Frailty : independent predictor of

– In-hospital mortality (OR = 1.8 ; 1.1 - 3) – Institutional discharge (OR = 6.3 ; 4.2 – 9.4) – Reduced midterm survival (OR = 1.5 ; 1.1 – 2.2)

• Age not predictor for these 3 primary outcomes

Lee Circulation 2010, 121: 973-978

Risk prediction models

• Society of Thoracic Surgeons (STS) score

– http://riskcalc.sts.org/stswebriskcalc/#/calculate

• Amber score
• EuroSCORE
• ...

But

• Consider peri-operative mortality +++
• Not really validated in high risk patients
• Morbidity ?
• Cognitive and functional capacity ?

Rosenhek European Heart Journal (2012) 33, 822–828

Decision Making on Patients Referred for TAVR

Lindman JACC interventions 2014; 7, 7 : 707-716

Determinants in treatment decision-making

• Surgical Replacement vs TAVI

geriatric components

– age OR = 0.790 (p < 0.001) – Comorbidity score OR = 0.86 (p = 0.027) – Functional status OR = 1.46 (p < 0.001) – Gait speed OR = 0.23 (p < 0.001).

• Surgical Replacement vs TAVI

cardiac components

– History previous cardiac surgery OR = 0.09 (p < 0.001) – Left ventricular ejection fraction <50% OR = 0.14 (p < 0.001) – Coronary artery disease requiring revascularisation OR = 0.4 (p = 0.019)

• TAVI vs. medical treatment

– history of previous cardiac surgery and presence of another severe valve disease

Boureau AS Maturitas 82 (2015) 128–133

To evaluate patient’s choice

• Elderly heart failure (HF) patients prefers

longevity over QoL*

• Key characteristics of shared decision-making**

– that at least two participants--physician and patient be involved; – that both parties share information; – that both parties take steps to build a consensus about the preferred treatment; – an agreement is reached on the treatment to implement.

*Brunner-La Rocca European Heart Journal (2012) 33, 752–759 **Charles Soc. Sci. Med. 1977, Vol.44, No. 5, pp. 681-692

When does transapical aortic valve replacement become a futile procedure

• Patient selection is crucial to achieve good outcomes and to

avoid futile procedures in patients undergoing transcatheter aortic valve replacement

• Futility was defined as mortality within 1 year after

transapical transcatheter aortic valve replacement in patients surviving at 30 days

• The multivariate analysis identified the following as

independent predictors of futility: insulin-dependent diabetes (odds ratio, 3.1; P . .003), creatinine 2.0 mg/dL or greater or dialysis (odds ratio, 2.52; P . .012), preoperative rhythm disorders (odds ratio, 1.88; P . .04), and left ventricular ejection fraction less than 30% (odds ratio, 4.34; P . .001).

D’Onofrio J Thorac Cardiovasc Surg 2014;148:973-80

Integrated approach for estimating transcatheter aortic valve implantation-specific risk and futility

Puri European Heart Journal (2016) 37, 2217–2225

Transition to palliative care when transcatheter aortic valve implantation is not an option

• The goal of eligibility assessment is to answer two

clinical questions:

– Can TAVI be done? – Should TAVI be done?

• The decision to not offer TAVI ‘should not equate to

abandoning care’ ;

• TAVI programs could promote the transition from a

procedure-focused program to palliative care to manage a poor prognosis and limited life expectancy associated with end-stage valvular heart disease

Lauk Curr Opin Support Palliat Care 2016, 10:18–23

Indications TAVI: should we go further ?

• Patients at intermediate risk for surgery ?
• Patients with asymptomatic AS ?
• Patients at very high risk ?

Trends in population characteristics in patients treated with TAVI

• 2010-2013, 429 pts, mean age 84.1 ± 6.7 y
• Decrease :

– mean logistic EuroSCORE 19.4 ± 10.9% to 15.8 ± 8.7% (P = 0.01). – Mean length of stay after TAVI 8.9 ± 11.3 days to 4.8 ± 4.7 days (P = 0.002).

• No change

– 30-day mortality rate (6.4% vs. 5.6%;P = 0.99). – major vascular complications (12.8% vs. 15.4%; P = 0.87) and stroke(2.1% vs. 1.4%; P = 0.75).

• Increase :

– one-year survival 81.0% to 94.4% (P = 0.03).

Avinée Archives of cardiovascular diseases 2016, 109:457-464

Indications TAVI: should we go further ?

• Knowledge Gaps in Cardiovascular Care of the Older

Adult Population*

• Risk calculators should be developed
• Potential role of medical therapies in slowing the

rate of disease progression and reducing symptoms remains to be established

• Novel techniques are needed to reduce

periprocedural complications

• Improved methodologies and criteria are needed

to refine patient selection

• Rich J Am Coll Cardiol 2016;67:2419–40

Indications TAVI: should we go further ?

• Patients at intermediate risk for surgery ?
• Patients with asymptomatic AS ?
• Patients at very high risk ?

Trial needed Ethics