In the Journals

Elderly patients may fare better with TAVR vs. surgery

Sameer Arora
Sameer Arora

Patients aged 80 to 89 years with aortic stenosis may experience better outcomes after transcatheter aortic valve replacement, as compared with surgical AVR, according to new data.

“We did this study in part because, in our clinical experience, we observed that patients above 80 years old tended to do better with TAVR over surgical AVR, regardless of their calculated surgical risk. We felt that there were octogenarians whose surgical risk wasn’t truly reflected in their low Society of Thoracic Surgeons risk scores. What isn’t captured in the scores is lack of physiologic reserve that happens as we get older. We wanted to see if national data supported what we were observing in our institution. We were pleased to see that it did,” Sameer Arora, MD, from the division of cardiology at the University of North Carolina School of Medicine, Chapel Hill, wrote in an email to Cardiology Today’s Intervention.

Lower incidence of adverse events

From 2012 to 2015, Arora and colleagues found that TAVR, as compared with surgical AVR, in octogenarians, was linked to less acute kidney injury, bleeding, blood transfusions and cardiogenic shock. The proportion of home discharges was also higher with TAVR. However, TAVR was associated with more permanent pacemaker implantations and vascular complications.

Notably, when stratified according to comorbidity burden, the reduction in median length of hospital stay was more pronounced among patients with higher Charlson Comorbidity Index (CCI) scores.

After weighting, TAVR vs. surgical AVR was associated with a lower likelihood of acute kidney injury (OR = 0.55; 95% CI, 0.45-0.68), bleeding (OR = 0.44; 95% CI, 0.37-0.53), blood transfusions (OR = 0.36; 95% CI, 0.3-0.44), cardiogenic shock (OR = 0.55; 95% CI, 0.33-0.92) or transfer to a skilled nursing facility (OR = 0.34; 95% CI, 0.29-0.41). Length of hospital stay also remained significantly shorter with TAVR.

There were no significant differences in the odds of permanent pacemaker implantation, transient ischemic attack or stroke, cardiac arrest, vascular complications or in-hospital mortality between the two groups.

Among TAVR hospitalizations, when stratified by the endovascular (85%) or transapical approach (15%), only the endovascular approach was linked to shorter length of hospital stay and lower odds of acute kidney injury or cardiogenic shock, as compared with surgical AVR. The endovascular approach was also associated with increased odds of permanent pacemaker implantation. Both approaches were associated with a lower likelihood of bleeding and blood transfusion.

“The results from this nationally representative study confirmed our experiences of treating these patients in the clinical setting,” Arora said. “Octogenarians represent a population of low physiological reserve and higher frailty and are likely to fare better with TAVR than surgical AVR.”

In the retrospective cohort study based on the National Inpatient Sample (NIS), the researchers evaluated hospitalizations for TAVR (n = 19,145) or surgical AVR (n = 9,815) involving patients aged 80 to 89 years from 2012 to 2015. Patients who underwent TAVR tended to be older and had a higher median CCI score.

Future of TAVR for octogenarians

The study has several limitations, the researchers noted, including the lack of data on Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) and EuroSCORE II risk scores and the fact that the NIS tracks data at the hospitalization level, not the patient level.

Despite these limitations, the study offers a compelling reason to select TAVR over surgery in octogenarians, Dominique Himbert, MD; Marina Urena, MD, PhD; and Gregory Ducrocq, MD, PhD, all from the cardiology department, CHU Bichat-Claude Bernard, AP-HP, Paris, wrote in an accompanying editorial. The question, they noted, is why this patient population is still referred for surgery when transfemoral TAVR is possible.

A lack of high-level evidence in the form of randomized trials is likely to blame, the editorialists wrote, as are the varied opinions of the heart team treating these patients. Current data suggest that TAVR is increasing among younger octogenarians, particularly in Europe, but not among those older than 85 years, they added.

Age and frailty are important factors for considering a less invasive treatment option such as TAVR over surgical AVR, but “at a country or center level, the translation of this large consensus into clinical practice still remains heterogeneous. With the expected results of low-risk TAVR randomized trials in the next few months, the continued technological improvements and the demographic projections, there is no doubt that TAVR will rapidly and universally become standard of care in octogenarians with severe aortic stenosis,” the editorialists wrote.

There are other aspects of TAVR in this population that also warrant further investigation, according to Arora.

“As our study investigated in­hospital outcomes, it would be interesting to investigate if these results persist in longer-term follow-up as well. Furthermore, a study comparing TAVR and surgical AVR restricted to low­surgical­risk octogenarians will provide important information,” he told Cardiology Today’s Intervention. – by Melissa Foster

For more information:

Sameer Arora, MD, can be reached at saror@email.unc.edu; Twitter: @sameeraroramd.

Disclosures: Arora reports his spouse has a proprietary role in researchEZ LLC. Please see the study for all other authors’ relevant financial disclosures. Himbert reports he is a proctor for Edwards Lifesciences and Medtronic. Urena and Ducrocq report no relevant financial disclosures.

Sameer Arora
Sameer Arora

Patients aged 80 to 89 years with aortic stenosis may experience better outcomes after transcatheter aortic valve replacement, as compared with surgical AVR, according to new data.

“We did this study in part because, in our clinical experience, we observed that patients above 80 years old tended to do better with TAVR over surgical AVR, regardless of their calculated surgical risk. We felt that there were octogenarians whose surgical risk wasn’t truly reflected in their low Society of Thoracic Surgeons risk scores. What isn’t captured in the scores is lack of physiologic reserve that happens as we get older. We wanted to see if national data supported what we were observing in our institution. We were pleased to see that it did,” Sameer Arora, MD, from the division of cardiology at the University of North Carolina School of Medicine, Chapel Hill, wrote in an email to Cardiology Today’s Intervention.

Lower incidence of adverse events

From 2012 to 2015, Arora and colleagues found that TAVR, as compared with surgical AVR, in octogenarians, was linked to less acute kidney injury, bleeding, blood transfusions and cardiogenic shock. The proportion of home discharges was also higher with TAVR. However, TAVR was associated with more permanent pacemaker implantations and vascular complications.

Notably, when stratified according to comorbidity burden, the reduction in median length of hospital stay was more pronounced among patients with higher Charlson Comorbidity Index (CCI) scores.

After weighting, TAVR vs. surgical AVR was associated with a lower likelihood of acute kidney injury (OR = 0.55; 95% CI, 0.45-0.68), bleeding (OR = 0.44; 95% CI, 0.37-0.53), blood transfusions (OR = 0.36; 95% CI, 0.3-0.44), cardiogenic shock (OR = 0.55; 95% CI, 0.33-0.92) or transfer to a skilled nursing facility (OR = 0.34; 95% CI, 0.29-0.41). Length of hospital stay also remained significantly shorter with TAVR.

There were no significant differences in the odds of permanent pacemaker implantation, transient ischemic attack or stroke, cardiac arrest, vascular complications or in-hospital mortality between the two groups.

Among TAVR hospitalizations, when stratified by the endovascular (85%) or transapical approach (15%), only the endovascular approach was linked to shorter length of hospital stay and lower odds of acute kidney injury or cardiogenic shock, as compared with surgical AVR. The endovascular approach was also associated with increased odds of permanent pacemaker implantation. Both approaches were associated with a lower likelihood of bleeding and blood transfusion.

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“The results from this nationally representative study confirmed our experiences of treating these patients in the clinical setting,” Arora said. “Octogenarians represent a population of low physiological reserve and higher frailty and are likely to fare better with TAVR than surgical AVR.”

In the retrospective cohort study based on the National Inpatient Sample (NIS), the researchers evaluated hospitalizations for TAVR (n = 19,145) or surgical AVR (n = 9,815) involving patients aged 80 to 89 years from 2012 to 2015. Patients who underwent TAVR tended to be older and had a higher median CCI score.

Future of TAVR for octogenarians

The study has several limitations, the researchers noted, including the lack of data on Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) and EuroSCORE II risk scores and the fact that the NIS tracks data at the hospitalization level, not the patient level.

Despite these limitations, the study offers a compelling reason to select TAVR over surgery in octogenarians, Dominique Himbert, MD; Marina Urena, MD, PhD; and Gregory Ducrocq, MD, PhD, all from the cardiology department, CHU Bichat-Claude Bernard, AP-HP, Paris, wrote in an accompanying editorial. The question, they noted, is why this patient population is still referred for surgery when transfemoral TAVR is possible.

A lack of high-level evidence in the form of randomized trials is likely to blame, the editorialists wrote, as are the varied opinions of the heart team treating these patients. Current data suggest that TAVR is increasing among younger octogenarians, particularly in Europe, but not among those older than 85 years, they added.

Age and frailty are important factors for considering a less invasive treatment option such as TAVR over surgical AVR, but “at a country or center level, the translation of this large consensus into clinical practice still remains heterogeneous. With the expected results of low-risk TAVR randomized trials in the next few months, the continued technological improvements and the demographic projections, there is no doubt that TAVR will rapidly and universally become standard of care in octogenarians with severe aortic stenosis,” the editorialists wrote.

There are other aspects of TAVR in this population that also warrant further investigation, according to Arora.

“As our study investigated in­hospital outcomes, it would be interesting to investigate if these results persist in longer-term follow-up as well. Furthermore, a study comparing TAVR and surgical AVR restricted to low­surgical­risk octogenarians will provide important information,” he told Cardiology Today’s Intervention. – by Melissa Foster

For more information:

Sameer Arora, MD, can be reached at saror@email.unc.edu; Twitter: @sameeraroramd.

Disclosures: Arora reports his spouse has a proprietary role in researchEZ LLC. Please see the study for all other authors’ relevant financial disclosures. Himbert reports he is a proctor for Edwards Lifesciences and Medtronic. Urena and Ducrocq report no relevant financial disclosures.