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Effect of Frailty on Survival After TAVR
Study Questions:
How do markers of frailty predict outcomes after transcatheter aortic valve replacement (TAVR)?
Methods:
This is a retrospective review of patients enrolled in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) registry, with linkage to Centers for Medicare and Medicaid Services (CMS) administrative claims data. Markers of frailty examined were serum albumin (low defined as <3.5 mg/dl), hemoglobin (anemia defined as <13 mg/dl for men and <12 mg/dl for women), and 5-meter walk test (slow defined as >6 seconds). Primary outcome was all-cause mortality at 30 days and 1 year after TAVR. Secondary outcomes included composite endpoints at 30 days and 1 year of: 1) all-cause mortality and readmission for heart failure; 1) stroke, myocardial infarction, any bleeding complication, and readmission for heart failure; and 3) length of stay ≥3 days for index admission. Multivariate unadjusted and adjusted Cox proportional hazards modeling was performed.
Results:
From November 2011 to June 2016, 56,500 patients ≥65 years old with no prior valve interventions underwent elective TAVR. Ultimately 23,460 patients for whom data could be linked to the CMS Mortality Database and for whom frailty markers were reported were used in the analysis. Median follow-up was 380 days. Mortality at 30 days worsened with increasing number of positive frailty markers, and patients with all three positive markers of frailty had an adjusted hazard ratio [HR] for death of 1.36 (95% confidence interval [CI], 1.01-1.84; p = 0.041). Similarly, at 1 year, patients with any positive marker of frailty had poorer survival, and patients with all three positive markers of frailty had an adjusted HR for death of 2.5 (95% CI, 2.08-3.01; p < 0.001). Low albumin was the single strongest predictor of 30-day and 1-year mortality (adjusted 1-year HR, 1.5; 95% CI, 1.4-1.6; p < 0.001). Patients with any positive frailty markers were more likely to experience the composite endpoint of all-cause mortality and readmission for heart failure at 30 days and 1 year. Length of stay also increased with increasing number of positive markers of frailty. There was no significant interaction between age and frailty.
Conclusions:
Patients with higher markers of frailty have significantly higher all-cause mortality and morbidity.
Perspective:
Frailty is both a qualitative and quantitative factor that affects outcomes for both medical conditions and surgical procedures. This study focused on markers that speak to nutritional reserve and mobility. A strength of the study is that it used data from a large registry of all US TAVR centers, in which participation is required by the National Coverage Determination. However, frailty components were not reported in 12,782 (35%) of the patients who could have been included in the analysis. Regardless, the results support that when considering TAVR in frail patients, proceed with caution. As indications for TAVR have broadened to include all patients with severe symptomatic aortic stenosis regardless of surgical risk, determining those who would most benefit from the procedure becomes more imperative. The study proposes a “Frailty Screening Workflow” (Figure 6) to help identify patients in the clinic who are more likely to be frail. Also, despite difficulties with data collection, when it comes to tests like the 5-meter walk test, this study shows that the information captured is important and well worth the extra effort, both for the patient and the STS/ACC TVT registry.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease
Keywords: Anemia, Aortic Valve Stenosis, Cardiac Surgical Procedures, Frail Elderly, Heart Failure, Heart Valve Diseases, Hemoglobins, Hemorrhage, Myocardial Infarction, Serum Albumin, Stroke, STS/ACC TVT Registry, Transcatheter Aortic Valve Replacement
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