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Functional Outcomes Differ in Older Patients After TAVR, SAVR

Frailty made a difference in whether older adults undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) actually saw functional improvement afterward, one center found.

After TAVR, the 12-month functional trajectories self-reported by patients from most to least common were: fair (minimal decline; 37.8%), good (improvement; 23.1%), poor (moderate decline; 14.7%), excellent (full recovery; 14.0%), and very poor (large decline; 8.4%).

For those who got SAVR, the trajectories tended to be better: good (37.9%), excellent (36.9%), fair (19.4%), poor (2.9%), very poor (1.0%), according to Dae Hyun Kim, MD, MPH, ScD, of Beth Israel Deaconess Medical Center in Boston, and colleagues in JAMA Internal Medicine.

Theirs was a single-center substudy (n=246) of a 1,020-person study. Included were adults, ages ≥70, who reported their ability to perform certain activities and physical tasks regularly over telephone interviews.

“Patients who followed more favorable trajectories had higher function before the procedure and recovered their preoperative function within 3 months, whereas those who had poor or very poor trajectories had lower preoperative function and remained persistently impaired,” Kim and colleagues observed.

How patients scored on a comprehensive geriatric assessment-based frailty index (CGA-FI) before the operation — comprising assessments such as the Mini-Mental State Examination and usual gait speed — also seemed to predict their functional trajectory.

TAVR patients with baseline CGA-FI scores of ≥0.20 had 100% good-excellent outcomes; on the other hand, the frailer 0.51-plus group largely had poor (45.5%) or very poor (22.7%) outcomes.

Similarly, patients going into SAVR with CGA-FI of ≥0.20 had mainly good-excellent outcomes 12 months later, whereas those in the 0.41-0.50 range had mostly a fair trajectory (71.4%).

“Although this nonrandomized study does not allow comparison of the effectiveness between TAVR and SAVR, anticipated functional trajectories may inform patient-centered decision making and perioperative care to optimize functional outcomes,” according to the authors.

They suggested that clinicians use their CGA-FI calculator to determine the best- and wort-case scenarios for each patient as part of the shared decision-making process.

In an accompanying editorial, Carolyn Seib, MD, and Emily Finlayson MD, MS, both of the University of California, San Francisco, said that “a focus on individualized and shared decision making in severe aortic stenosis is necessary to ensure that the priorities of patients are in line with anticipated outcomes following valve replacement.”

“With the large number of older patients with severe aortic stenosis who may be considered for TAVR, it is necessary to understand the expected outcomes that matter to older adults, including postoperative functional status,” they wrote.

In the study, postoperative delirium and major complications were also predictors of functional decline after TAVR and lack of improvement after SAVR.

Thus, efforts to implement “better surgical techniques or devices, safer anesthesia methods, and prevention of delirium may improve functional outcomes,” Kim’s group suggested, urging also that cardiac rehabilitation be used more.

The investigators noted that their findings came out of an academic center with high procedural volume and expertise, that had been performing TAVR with older-generation valves at the time of data collection.

“Caution is advised in applying our results to contemporary populations and less-experienced centers that may provide treatment for patients with a different frailty distribution,” they said.

“The results of this study require us to reevaluate the indications for TAVR in frail adults and recognize that improvement in disease-specific outcomes is not equivalent to improvement in outcomes that matter to older adults,” Seib and Finlayson maintained.

They noted that prior studies had relied on disease-specific outcomes such as heart failure symptoms, valve diameter, and mortality in comparing TAVR to SAVR or medical therapy.

Kim disclosed support from the National Institute on Aging, the American Federation for Aging Research, the John A. Hartford Foundation, Atlantic Philanthropies, the Boston Claude D. Pepper Older Americans Independence Center, and the Boston Roybal Center.

Finlayson disclosed a relevant relationship with Ooney. Seib disclosed no relevant relationships with industry.


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