Should TAVR Be Performed in Nonagenarians?
What are the outcomes of nonagenarians compared to younger patients undergoing transcatheter aortic valve replacement (TAVR) in current practice?
The investigators analyzed data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) Registry. Outcomes at 30 days and 1 year were compared between patients ≥90 versus <90 years of age using cumulative incidence curves. Quality of life was assessed with the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). The Cox proportional hazards models were used to assess the unadjusted and adjusted effects of age on 30-day and 1-year mortality.
Between November 2011 and September 2014, 24,025 patients underwent TAVR in 329 participating hospitals, of which 3,773 (15.7%) were age ≥90 years. The 30-day and 1-year mortality was significantly higher among nonagenarians (≥90 vs. <90: 30-day: 8.8% vs. 5.9%, p < 0.001; 1 year: 24.8% vs. 22.0%, p < 0.001, absolute risk 2.8%, relative risk 12.7%). However, nonagenarians had a higher mean STS Predicted Risk of Operative Mortality (PROM) score (10.9% vs. 8.1%; p < 0.001), and therefore had similar ratios of observed to expected rates of 30-day death (≥90 vs. <90: 0.81, 95% confidence interval, 0.70- 0.92 vs. 0.72, 95% confidence interval, 0.67-0.78). There were no differences in the rates of stroke, aortic valve reintervention, or myocardial infarction at 30 days or 1 year. Nonagenarians had lower (worse) median KCCQ-12 scores at 30 days; however, there was no significant difference at 1 year.
The authors concluded that available data support safety and efficacy of TAVR in select very elderly patients.
This study reports that in current US clinical practice, approximately 16% of patients undergoing TAVR are nonagenarians or older. Although 30-day and 1-year mortality rates were higher in this age group compared with younger TAVR patients, the absolute and relative differences were clinically modest and many nonagenarians have good outcomes after TAVR, with prolonged survival and improved quality of life, making TAVR reasonable to consider in select nonagenarians with severe aortic stenosis. It would seem reasonable that clinicians not deny TAVR solely based on patient age, but take into account individual risks and potential benefits.
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