Anatomical Versus Clinical Markers Of Frailty In Transcatheter Aortic Valve Replacement
Aravind Krishnan1, Alejandro Suarez-Pierre, MD1, Xun Zhou, MD1, Cheng T. Lin, MD1, Charles D. Frasier III, MD1, Todd C. Crawford, MD1, Joshua Hsu, ScM1, Rani K. Hasan, MD MHS1, Jon Resar, MD1, Matthews Chacko, MD1, John V. Conte, MD2, William A. Baumgartner, MD1, Kaushik Mandal, MD MPH FES1.
1Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Penn State University Medical Center, Hershey, PA, USA.
Background Frailty is an important factor in risk-stratification for patients undergoing transcatheter aortic valve replacement (TAVR). Most frailty assessment tools center around muscle weakness and failure to thrive, but can be difficult to measure in routine clinical practice and incorporate into prognostication. As a result, a range of surrogates for frailty have emerged: sarcopenia, an anatomical approximation of muscle weakness; the modified frailty index (mFI), a tool for the clinical assessment of frailty; and albumin, a marker of nutritional deficiency. We sought to compare the interrelationship and ability of these surrogates in predicting outcomes after TAVR.
Methods This was a retrospective, single-institution study of patients undergoing TAVR from 2011-2016. Indexed cross-sectional areas of the lumbosacral muscles were used to assess sarcopenia. mFI was calculated using a 11-point scale incorporating readily available clinical characteristics. Patient demographics, operative characteristics, STS predicted risk of mortality (STS-PROM), and outcomes were reviewed. The primary outcome was one- and two-year all-cause mortality. Adjusted survival analysis was used to compare outcomes.
Results 428 patients underwent TAVR at our institution from 2011 to 2016. 47 patients were excluded due to incomplete records. Sarcopenia of the psoas muscles determined by our cutoffs was associated with one- (OR: 2.8, p=0.03) and two-year (OR: 2.5, p=0.05) mortality. High albumin levels were associated with decreased risk of one- (OR: 0.2, p<0.01) and two-year (OR:0.3, p<0.01) mortality. Neither sarcopenia of the paravertebral muscles nor mFI was associated with mortality. Among patients with psoas muscle sarcopenia, multivariate Cox regression showed a 2.2 hazard ratio (p=0.04) for mortality at 2 years, and a Kaplan Meier analysis demonstrated decreased survival at one-year (p=0.02) and at two-years (p=0.03). Additionally, the inclusion of psoas sarcopenia into the STS-PROM score improved its C-statistic.
Conclusions In this study, only sarcopenia of the psoas muscles and low albumin levels were associated with one- and two-year mortality in TAVR patients. After prospective validation, these tools may aid clinicians in risk stratification prior to TAVR. This is the first assessment of the modified frailty index in TAVR patients, as well as the first head-to-head comparison of each of these surrogates for frailty.
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