Laura M Drudi1, Matthew Ades2, Anita Asgar3, Louis Perrault4, Sandra Lauck5, John G Webb5, Andrew Rassi6, Andre Lamy7, Nicolas Noiseux8, Mark D Peterson9, Marino Labinaz10, Thierry Lefèvre11, Jeffrey J Popma12, Dae H Kim13, Giuseppe Martucci14, Nicolo Piazza14, Jonathan Afilalo15. 1. Divisions of Cardiology & Clinical Epidemiology, Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, Quebec, Canada; Division of Vascular Surgery, McGill University, Montreal, Quebec, Canada. 2. Divisions of Cardiology & Clinical Epidemiology, Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, Quebec, Canada; Division of Internal Medicine, McGill University, Montreal, Quebec, Canada. 3. Division of Cardiology, Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada. 4. Division of Cardiac Surgery, Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada. 5. Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada. 6. Department of Cardiology, Kaiser Permanente - San Francisco Medical Center, San Francisco, California. 7. Division of Cardiac Surgery, Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada. 8. Division of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Centre de Recherche du CHUM, Montreal, Quebec, Canada. 9. Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. 10. Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. 11. Division of Interventional Cardiology, Institut cardiovasculaire Paris Sud, Ramsay-générale de santé, Hôpital privé Jacques Cartier, Massy, France. 12. Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts. 13. Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts. 14. Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada. 15. Divisions of Cardiology & Clinical Epidemiology, Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, Quebec, Canada; Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada. Electronic address: jonathan.afilalo@mcgill.ca.
Abstract
OBJECTIVES: The authors sought to determine whether frail older adults undergoing nonfemoral transcatheter aortic valve replacement (TAVR) procedures had a higher risk of 30-day and 12-month mortality. BACKGROUND: Frailty can help predict outcomes and guide therapy in older adults being considered for TAVR. Nonfemoral TAVR procedures are more invasive and impart a greater risk of adverse events, which may be less well tolerated in frail patients, compared with transfemoral TAVR procedures. METHODS: This study was a post hoc analysis of the FRAILTY-AVR (Frailty Assessment Before Cardiac Surgery & Transcatheter Interventions) prospective multicenter cohort that consisted of older adults undergoing TAVR from 2012 to 2017. Frailty was assessed using the Essential Frailty Toolset (EFT). Endpoints of interest were 30-day and 12-month all-cause mortality. Interaction tables and multivariable logistic regression models were used to investigate statistical interaction on the additive and multiplicative scales. RESULTS: The cohort consisted of 723 patients with a mean age of 84 ± 6 years, of which 556 (77%) had femoral access and 167 (23%) had nonfemoral access. In frail patients with EFT scores ≥3 (35%), nonfemoral access was associated with increased 30-day mortality (odds ratio [OR]: 3.91; 95% confidence interval [CI]: 1.48 to 10.31); whereas in nonfrail patients with EFT scores <3 (65%), nonfemoral access had no effect (OR: 1.29; 95% CI: 0.34 to 4.94). There was statistical evidence of interaction between frailty and access site on 30-day mortality on the additive scale (relative excess risk due to interaction = 5.95). Nonfemoral access was associated with increased 1-year mortality in frail patients (OR: 1.98; 95% CI: 1.00 to 3.93) but not in nonfrail patients (OR: 1.83; 95% CI: 0.90 to 3.74), although there was no statistical evidence of interaction. CONCLUSIONS: Frail patients undergoing TAVR via a more invasive nonfemoral access face a substantially higher risk of 30-day mortality, whereas nonfrail older adults tolerate the procedure with a low short-term risk irrespective of access route.
OBJECTIVES: The authors sought to determine whether frail older adults undergoing nonfemoral transcatheter aortic valve replacement (TAVR) procedures had a higher risk of 30-day and 12-month mortality. BACKGROUND: Frailty can help predict outcomes and guide therapy in older adults being considered for TAVR. Nonfemoral TAVR procedures are more invasive and impart a greater risk of adverse events, which may be less well tolerated in frail patients, compared with transfemoral TAVR procedures. METHODS: This study was a post hoc analysis of the FRAILTY-AVR (Frailty Assessment Before Cardiac Surgery & Transcatheter Interventions) prospective multicenter cohort that consisted of older adults undergoing TAVR from 2012 to 2017. Frailty was assessed using the Essential Frailty Toolset (EFT). Endpoints of interest were 30-day and 12-month all-cause mortality. Interaction tables and multivariable logistic regression models were used to investigate statistical interaction on the additive and multiplicative scales. RESULTS: The cohort consisted of 723 patients with a mean age of 84 ± 6 years, of which 556 (77%) had femoral access and 167 (23%) had nonfemoral access. In frail patients with EFT scores ≥3 (35%), nonfemoral access was associated with increased 30-day mortality (odds ratio [OR]: 3.91; 95% confidence interval [CI]: 1.48 to 10.31); whereas in nonfrail patients with EFT scores <3 (65%), nonfemoral access had no effect (OR: 1.29; 95% CI: 0.34 to 4.94). There was statistical evidence of interaction between frailty and access site on 30-day mortality on the additive scale (relative excess risk due to interaction = 5.95). Nonfemoral access was associated with increased 1-year mortality in frail patients (OR: 1.98; 95% CI: 1.00 to 3.93) but not in nonfrail patients (OR: 1.83; 95% CI: 0.90 to 3.74), although there was no statistical evidence of interaction. CONCLUSIONS: Frail patients undergoing TAVR via a more invasive nonfemoral access face a substantially higher risk of 30-day mortality, whereas nonfrail older adults tolerate the procedure with a low short-term risk irrespective of access route.