Tavr In Nonagenarians: To Do Or Not To Do
Luigi Pirelli, Karthik Seetharam, Nirav Patel, Derek Brinster, Jonathan Hemli, Jacob Scheinerman, Valvanur Subramanian, Efstathia Mihelis, Chad Kliger.
Northwell- Lenox Hill, New York, NY, USA.
Objective: Transcatheter aortic valve replacement (TAVR) has revolutionized aortic stenosis (AS) treatment. The nonagenarian population is increasing worldwide due to significant advances in health care. Clinicians are faced with the dilemma of whether benefits of TAVR outweigh the periprocedural risks and whether transcatheter interventions portend a better outcome than medical management. We sought to evaluate the short and mid-term outcomes in a series of 10 consecutive nonagenarian patients who underwent TAVR for severe symptomatic AS at our institution. Methods: We retrospectively examined a total of 10 nonagenarian patients who underwent TAVR from January 2016 to June 2018. All patients were diagnosed with severe symptomatic AS and were evaluated by a multidisciplinary team. All were deemed high risk for open surgical aortic valve replacement (SAVR) due to age, frailty criteria and multiple comorbidities. Results: Mean age was 92.6±2.6 and 70% (7/10) of the patients were female. 20% of patients had a history of previous cardiac surgery. The mean LV ejection fraction was 54.7±15.5 %. The preoperative mean aortic valve area was 0.66±0.22 cm2 and mean aortic gradient was 47.5±9 mmHg. The mean STS risk score for surgical AVR was 6%±4. TAVR was successfully performed in all 10 patients with no conversion to surgical aortic valve replacement. Self-expandable Medtronic Evolut R (Core Valve) were implanted in 8 patients (80%) and balloon expandable Edwards Sapien valves in the remaining 2 (20%). The operative mortality was 0 (0%). No neurologic complications were recorded. Post-implantation paravalvular leak (PVL) was mild in 5 (50%) of patients and moderate in 2 (20%). Fifty % of the patients required implantation of permanent pacemaker. Three patients (30%) were discharged on oral anticoagulant therapy. At follow-up, 7 patients (70%) were alive and had improved functional class at 1 year. Transthoracic echocardiography at 1 year revealed mean AVA was 1.9±.15 with a mean aortic gradient of 5.9± 3.31 mm Hg. The mean ejection fraction was 57.12±9.9. There was no neurological events at follow-up. Conclusion: Current trends in global health care are depicting significant increases in patient longevity and expansion of nonagenarian population. TAVR presents as viable alternative for patients deemed high risk for SAVR. Further investigation with larger trials and long term follow up is necessary.
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