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

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

Comorbidities and aortic stenosis Associated cardiac disease Non cardiac comorbidities • Chronic kidney disease (eGFR<60 ml/min/1.73 • Coronary ischemic disease 43.7% m 2 53.7% – Previous AMI 17.5% • Hypertension 82.9% – Previous PCI/CABG 28.3% • Hypercholesterolemia 60% • 204.5 ± 60.46 LVMI (g/m2) – Statin 53.3% LVMI >125 g/m2 93% • COPD 25.4% • FEVG ≤50% 28.7% • Diabetes 30% – Severe EF < 30% 6.2% • Anemia 48.75% • Pulmonary hypertension 67% – < 10 g/dl 13.2% – Severe sPAP > 60 mm Hg 8.3% • Cerebrovascular disease 30.8% • Aortic regurgitation 17% – Previous stroke 7% – • Carotid atherosclerosis 23.7% Atrial fibrillation 35.4% • Peripheral artery disease 11.6% • Pace-maker 18.3% • Abdominal aortic aneuvrysm 4.6% • Left bundle branch block 12.5% • Cancer 26.6% – New diagnosis 5.4% – Previous 21;2% Faggiano International Journal of Cardiology 159 (2012) 94 – 99

TAVI : predictors of increased risk Geriatric predictors Clinical predictors • Severely reduced left ventricular function • Advanced frailty • Very low transvalvular gradient (mean • Disability in activities of daily living gradient <20 mm Hg) • Malnutrition • Low flow (low stroke volume index, <35 • Mobility impairment ml/m2) • Low muscle mass and strength • Severe myocardial fibrosis (“ sarcopenia ”) • Severe concomitant mitral and/or • tricuspid valve disease Cognitive impairment • Severe pulmonary hypertension (PASP !60 • Mood disorders (depression, anxiety) 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%) 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 ? Trial needed • Patients at very high risk ? Ethics