Safe for 80-Year-Olds. Should Nonagenarians be Withheld from TAVR?

According to this large global registry, mortality after transcatheter aortic valve replacement (TAVR) is twice as high in nonagenarians as against the “younger” group (<90) despite their lower prevalence of comorbidities at baseline.

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Moreover, nonagenarians present higher risk of stroke, major or life-threatening bleeding and new atrial fibrillation. The STS-PROM is the only surgical risk score that can predict mortality risk in this group.

The prevalence of aortic stenosis is increasing along with life expectancy. In this regard, there is little information on the evolution of our >90 patients. Additionally, risk scores cannot be trusted given that on the one hand they were designed for patients with planned surgery, and on the other hand, they included few patients this old.

The CENTER (Cerebrovascular EveNts in Patients Undergoing TranscathetER Aortic Valve Implantation) was a collaborative study including 12381 patients with registries from 3 countries, 6 multicenter registries and one prospective clinical study.

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Primary end point was the difference in 30-day mortality and stroke after TAVR in nonagenarian vs. younger patients. Secondary end points included baseline characteristics, inhospital outcomes and the differences in accurate prediction of events from the EuroSCORE log, the EuroSCORE II and the STS-PROM in this special population.

A total 882 nonagenarian patients and 11499 sub-90 undergoing transfemoral TAVR were included between 2017 and 2018.

Nonagenarian presented significantly fewer comorbidities than the younger cohort.

In spite of that, mortality rate at 30 days resulted nearly twice as high in nonagenarians (9.9% vs. 5.4%; RR: 1.8; CI 95% 1.4 to 2.3; p=0.001), as was inhospital stroke (3.0% vs. 1.9%; RR: 1.5; CI 95% 1.0 to 2.3; p=0.04), major or life threatening bleeding (8.1% vs. 5.5%; RR: 1.6; CI 95% 1.1 to 2.2; p=0.004) and the development of new atrial fibrillation (7.9% vs. 5.2%; RR: 1.6; CI 95% 1.1 to 2.2; p=0.01).

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The only score that adequately estimated mortality risk in this special group (with observed to expected mortality ratio equal to 1.0) was the STS-PROM.

However, being over 90 is no reason to withhold patients from any procedure, and we have known since the first PARTNER what medical treatment results in.

It is vital for patients to be assessed by the “Heart Team”, and for them to determine if their life expectancy is longer than 1 year. In this case, there is no reason to withhold nonagenarian patients from TAVR.

Original title: Transfemoral TAVR in Nonagenarians.

Reference: Wieneke Vlastra et al. J Am Coll Cardiol Intv 2019;12:911–20.

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