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Effect of Malnutrition on TAVR Outcomes
Study Questions:
How does malnutrition prior to aortic valve replacement (AVR) impact mortality?
Methods:
The FRAILTY-AVR prospective cohort study examined 1,158 patients from 14 centers aged ≥70 years treated with transcatheter AVR (TAVR) or surgical AVR (SAVR), and evaluated the relationship between outcomes and measures of nutritional status and frailty. Nutritional assessment was performed by trained observers, and patients were evaluated using a 14-point scale (≤7 was considered malnourished). Frailty also was assessed by trained observers using a 12-point scale, with scores ≤5 considered severely frail. The primary outcome was mortality at 1 year.
Results:
There were 727 patients with TAVR and 431 individuals with SAVR. Mean age was 81 years. A total of 9% of patients were classified as malnourished, and 33% were classified as at-risk for malnutrition. Worse nutritional scores were correlated with worse frailty scores (r = 0.31). Malnourished individuals had higher unadjusted mortality at 1 year than those with normal nutritional status (28% vs. 10%, p < 0.01). After multivariable adjustment, variables independently associated with mortality at 1 year included malnutrition (odds ratio [OR], 1.08 per point decrease in scale), frailty (OR, 1.14 per point decrease in scale), Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) score (OR, 1.10 per %), and TAVR (vs. SAVR) procedure (OR, 1.63).
Conclusions:
Poor baseline nutritional status is associated with a significant increase in mortality following AVR.
Perspective:
In the era of TAVR, valve procedures are often considered in older and sicker patients who would not have been candidates for treatment in the past. This study finds that nutritional status and frailty are important and independent risk factors for mortality, and the unadjusted analysis observes that malnourished patients had nearly 3 times the rate of mortality at 1 year as those with normal nutritional status. An advantage of this study is that it quantified both nutritional status and frailty using validated questionnaires administered by trained assistants, and did not rely on self-reported metrics. Applying these findings to clinical practice may help us identify patients at increased risk from AVR, and may be superior to the “eyeball” test frequently used when we subjectively assess patients for possible intervention. Whether interventions to improve the nutritional status of malnourished patients would change outcomes remains to be seen.
Keywords: Aortic Valve, Cardiac Surgical Procedures, Frail Elderly, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Malnutrition, Nutrition Assessment, Nutritional Status, Risk Factors, Transcatheter Aortic Valve Replacement
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