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PreoperativeAssessment of OlderPatients Undergoing
TAVRThe Geriatrician’s Role in the Heart Team
Catherine Talbot-Hamon, MD, FRCP
Assistant Professor, Department of Geriatric Medicine McGill University
CGS Resident Day
April 19, 2018
Faculty/Presenter Disclosure
Faculty: Catherine Talbot-Hamon
Relationships with commercial interests: Grants/Research Support: none
Speakers Bureau/Honoraria: none
Consulting Fees: none
Other: Assistant Professor, Division of Geriatric Medicine, McGill University
CFPC CoI Templates: Slide 1
Disclosure of Commercial Support
• This speaker has received financial support from the Richard and Edith Strauss Foundation in the form of an educational grant.
• Potential for conflict(s) of interest:• None to disclose.
CFPC CoI Templates: Slide 2
Mitigating Potential Bias
- Nor the Strauss Foundation or McGill University have interests in the subjects to be discussed during this presentation.
CFPC CoI Templates: Slide 3
Objectives
At the end of the session, the participant will be able to:
describe TAVR procedure and expected outcomes in older patients;
discuss factors related to poor prognosis in TAVR;
and discuss the pertinence and components of a preoperative geriatric assessment in patients undergoing TAVR.
Outline
Overview of aortic stenosis
Before TAVR – historical perspective on treatment of
aortic stenosis
TAVR – what it’s about
TAVR outcomes review
Trying to predict outcomes in TAVR – the input of
geriatrics.
Now what? – Future directions.
Fall 2009 – GIM residents longitudinal clinic - JGH
99M, referred by cardiologist
“Critical aortic stenosis, for medical management”
Accomplished musician (violinist), composer
Blind, 24 hour caregiver
Exhaustion from minimal effort, angina at rest
Goal to get to 100…,
“…to get my letter from the Queen. She writes personally, you know…”
R. Lussen, 1800s
Aortic stenosis
Aortic valve thickening and calcification, causing a decrease in AVA and a pressure gradient
Etiology
Congenital valve abnormalities
Calcific disease of a normal trileaflet valve
Rheumatic valve disease
Prevalence1
70-79 y:3.9%
80-89 y: 9.8%
Zakkar et al. BMJ. 2016.1. Eveborn et al, Heart, 2013
Aortic stenosis - stages
Rashedi, J et al. Cardiovasc Ultrasound, 2015
Aortic stenosis – symptoms and prognosis
© 2018 UpToDate, Inc.
Historical perspective –cardiac procedures First successful open-heart procedure – Capellen,1895
Angiography – Moniz, 1927
First surgival aortic valve replacement (SAVR)– Harken, 1960
Coronary artery angiogram – Sones, 1960
First angioplasty – Gruentzig, 1977
Aortic stenosis - treatment
Medical
Aortic valve replacement
Indications
Severe high gradient AS with symptoms on history or exercise testing
Asymptomatic severe AS with EF < 50%
Severe AS undergoing other cardiac surgery
Asymptomatic very severe AS and low surgical risk
Asymptomatic AS with decreased exercise tolerance or fall in systemic BP with exercise
Asymptomatic AS, rapid progression, low surgical risk
Moderate AS undergoing other cardiac surgery
Decision to replace valve based on:
1. Symptoms2. AS grade/severity3. Individual patient’s surgical
risk4. Other
(Nishimura et al. Circulation. 2014)
Surgical Risk Assessment
TS Risk Score Patient, cardiac and
surgery-related riskfactors (50 variables)
% 30 day mortality*
Performance in olderpatients undergoing AVR
In ≥ 80 y, AUC 0.81 (Vanhuyse et al, 2013)
Superior to EuroSCOREfor high risk patients (Kuwaki et al, 2015)
Logistic EuroSCORE II Patient, cardiac and
surgery-related riskfactors (17 variables)
% 30 day mortality*
Performance in olderpatients undergoing AVR
In ≥ 70y, AUC <0.7 (Pullis et al, 2015)
In ≥ 80 y, same poorAUC, worse in high riskcategory (Provenchereet al, 2017)
Limits of SAVR
‘Futility’
Limited life expectancy (‹ 12 mo)
Risk-related contra-indications
Prohibitive (extreme) risk patients (Estimated risk of mortality or major morbidity › 50% at 30 d)
Non-risk-related contra-indications
Absolute
Porcelain aorta
Hostile chest
Relative
Frailty, severe liver disease/cirrhosis, severe PH, etc.
2014 AHA/ACC Guideline for the Management of Patients with Valvular Hear Disease – JACC (2014)
Historical perspective –cardiac procedures
Balloon aortic valvuloplasty - 1991
First transcatheter aortic valve replacement (TAVR) on a human – Cribier, 2002
PARTNER 1 - trial
(Svensson al. J Thoracic and Cardiovasc Surg, 2013)
CoreValve trial
(Haussig and Linke, Circulation. 2014)
n=390 n=357
LANDMARK STUDIES - OUTCOMESPARTNER 1A COREVALVE US
PIVOTAL TRIALPARTNER 1B COREVALVE
EXTREME RISK
ONE YEAR
All causemortality (%)
24.2 vs 26.6 13.9 vs 18.7* 30.7 vs 50.7* 24,3
Death + rehospit.(%)
34.6 vs 35.9 42,5 vs 75.6*
Δ KCCQ 31.8 vs 4.1* 24.0 vs 21.9 24.2 vs 10.4* 27.4
COMPLICATIONS (30d)
Major stroke (%) 3.8 vs 2.1 4.9 vs 6.2 5.0% vs 1.1 (p=0.06)
2.3
Vascularcomplications (%)
11.0 vs 3.2* 5.9 vs 1.7* 16.2 vs 1.1* 8.2
Major bleeding (%) 9.3 vs 19.5* 28.1 vs 34.5* 16.8 vs 3.9* 36.7
(Leon, Smith et al. NEJM. 2010)(Smith, Leon et al. NEJM 2011)
(Adams, Popma et al. JACC. 2014)(Popma, Adams et al. NEJM 2014)
KCCQ: Kansas City Cardiomyopathy Questionnaire
Historical perspective –cardiac procedures
FDA approval of TAVR – 2011 (inoperable)
- 2012 (high risk)
Creation of the STS/ACC TVT registry - 2012
TAVR - Procedure
https://www.youtube.com/watch?v=csxJYTLXNJY
TAVR – “long term” outcomesExtreme risk
(Makkar, Fontana et al.NEJM, 2012)
TAVR - “long term” outcomesHigh risk
(Kodali et al. NEJM, 2012.Reardon et al. JACC, 2015
Deeb et al. JACC. 2016)
Quality of Life in TAVR Inoperable patients
Quality of Life in TAVR
High risk patients
Concept of “poor outcome” n TAVR
Came from realization that in patients undergoing TAVR (older, multiple comorbidities):
Redefined ‘successful outcome’ in TAVR as the composite of:
‘survival alone (without improved QoL) would not be viewed as a desirable outcome’ – Arnold
Death Very poor QoL (KCCQ OS < 45) Important decline in QoL compared to baseline (decrease of 10 points on KCCQ OS)
(A ld t l Ci l ti 2014)
Prevalence of poor outcome
PARTNER 6 months: 33%
One year: 50%
COREVALVE 6 months: 31,2%
One year: 50,8%
(Arnold et al. Circulation. 2014)(Arnold et al. JACC. 2016)
Poor outcomes in TAVR -Predictors
PARTNER6 min walk test (per 10 m) –OR 0,97* (0,96-0,98)
Mean aortic valve gradient (per 10 mmHg) – OR 0.82* (0.75–0.89)
MMSE (per 1 point) – OR 0.96* (0.92–1.00)
O2 dependent lung disease –OR 1.77* (1.23–2.54)
Serum creat (per 1mg/dL) –OR 1.32* (1.03–1.70)
Major arrhythmia – OR 1.29* (1.02–1.63)
CoreValve Same as PARTNER plus:
Frailty (Fried) – OR 1.29* (1.08–1.55)
Disability (per 1ADL) –OR 1.29* (1.19–1.39)
Unintentional weight loss – OR 1.51* (1.17–1.95)
C-statistic = 0.64
C-statistic = 0.65
OR
C-statistic 0.67
Geriatric measures in outcome prediction - TAVR
Frailty
Psoas muscle area
Gait speed
Mood
Comprehensive Geriatric Assessment
Frailty-TAVR1. Why bother so much?
It`s prevalent
33-76% patients (depending on definition)
It adds predictive value to traditional risk scores
It`s perceived as easily measurable in the office
It`s potentially reversible
(Talbot-Hamon et al. JAGS. 2017)(Afilalo et al JACC 2014)
Frailty – TAVR2. Associated Outcomes
arly (30 d)Mortality• 17 vs 6% (Puls,
2014)Length of stay• 9 vs 6 d (Green,
2012)Discharge to facility• OR 4.8 (Huded,
2016)
Intermediate
(6 months)• Mortality
• OR 1.8 (Osnabrugge, 2015)
• Poor outcome• OR 2.1
(Green, 2015)• ADL Δ ≥ 1
• OR 3.34 (Schoenenberger, 2013)
Long (1 year)• Mortality
• HR 2.5-3.5 (Green, 2012) (Green, 2015)
• Poor outcome• OR 1.42-
2.93 (Arnold, 2016) (Stortecky,2012)
Longer (2 years)• Mortality
• HR 2.28 (Bogdan, 2016)
• OR 2.15 (Cockburn)
Frailty-TAVR3. How to measure
In 2017 review:
Fried scale: 2
Custom scale – Fried adaptation: 3
Gait speed alone: 1
Katz ADL disability: 2
Albumin (different thresholds): 3
‘poor mobility’: 1
Recent fall: 1
SHERPA scale: 1
Psoas muscle area: 2
Total muscle area at L3: 1
Wheelchair bound: 1
Custom scale (CGA-derived): 2
Subjective: 2
Talbot-Hamon, JAGS. 2017.
Frailty in AVR – parenthesis on psoas muscle area
2 studies2,3
Rationale: 1/5 patients cannot undergoing assessment for TAVR cannot perform 5 m gait speed test1
Psoas muscle area good surrogate for muscle mass4 - > frailty
Readily available with routine CT scans pre-TAVR
In Mamane et al:
Associated with mortality in females HR 0.88/cm2 (CI 0.78-0.99) but not in males HR 1.01/cm2 (CI 0.93-1.10)
In Paknikar et al:
Gender-standardized TPA (total psoas area) associated with mortality HR 0.47, p = 0.02 and resource utilization OR 0.6 p<0.001
1.Green et al. JACC Cardiovasc Iterv. 2012.2.Mamane et al. Can J Cardiol. 2016
Gait speed alone as outcome predictor in TAVR
STS/ACC Transcatheter Valve Therapy Registry (USA)1
Optimized Catheter Valvular Intervention–Transcatheter Aortic Valve Implantation (OCEAN-TAVI, Japan)2
5 m gait speed cutoffs: Not able to walk
Slowest walkers (< 0.5 m/s)
Slow walkers (0.5-0.83 m/s)
Normal walkers (> 83 m/s)
Outcomes:
Slowest walkers aHR 1.35 (1.01-1.80) 30 d mortality1
Slowest walkers or unable to walk: aHR 2.01 (1.20-3.38) 1 y mortality2
Longer LOS (7 vs 5 days) and higher discharge to facility in slowest group2
1.(Alfredsson et al. Circulation. 2016)
Frailty – TAVR4. Latest news
Use of FORECAST score to predict short term outcomes in TAVR FORECAST (Frailty predicts death One yeaR after Elective
Cardiac Surgery Test)
Chair rise (3) - timed
Weakness – subjective, past 2 weeks
Stairs – as many as possible
Clinical frailty scale (CFS) – Rockwood and al, 2005.
Creatinine
Initially tested in patients undergoing cardiac surgery1:
Best predictor of one year mortality (compared to EuroScore and STS) – AUC 0.76, vs 0.67
Now tested in TAVR as predictor of 30 day mortality2:
ROC 0.73 alone and 0.77 when combined with STS (p=0.021)
1.(Sundermann et al. Eur J Cardiothorac Surg. 2011)
Frailty – TAVR4. Latest news
The Essential Frailty Tool (EFT) as predictor of mortality and disability in TAVR or SAVR (FRAILTY AVR study)
Large longitudinal cohort (›1000 patients)
Four items
Compared to other scales (Fried, Rockwood, SPPB, etc.) and found to have best fit.
Best predictor of:
30 d mortality: aOR 3.29 (1.73-6.26)
1 year mortality: aOR 3.72 (2.54-5.45)
1 year disability: aOR 2.13 (1.57-2.87)
(Afilalo et al. JACC. 2017)
Frailty and TAVR – what do guidelines say?
2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis Complete section on patient selection and evaluation,
suggesting:
Team-based approach
Functional assessment
Frailty
gait speed ‹0,5 m/s or ‹0,83 m/s with disability or cognitive impairment
Another scale
Nutritional risk status (albumin, BMI, MNA, history of weight loss)
Physical function (6MWT and functional assessment)
Cognitive function (MMSE, depression screen)
Futility (life expectancy)
Integrated risk-benefit and shared decision-making
Severe frailty considered prohibitive risk(Otto et al. JACC. 2017)
mportance of preoperative mood in TAVR
Subgroup analysis FRAILTY-AVR
GDS SF or history of depression
Outcomes with depression:
30 d mortality
aOR 2.20 (1.18-4.10)
1 year mortality
aOR 1.532 (1.03-2.24)
If persistent depression (6 months post-procedure) – aOR 2.98 (1.08-8.20)
(Drudi et al. JAMA Cardiol. 2018)
Benefits of involving geriatricians n patient selection
If many studies report on utility of a Geriatric Assessment (GA) in patient selection, only one was found reporting outcomes of a Comprehensive Geriatric Assessment (CGA)
France, outpatient geriatric assessment clinic
Study pop: 21 patients, mean age 85 y, mean gait speed 0.66 m/s, median MMSE 21/30.
Results:
Cardiologists followed 100% recommendations of NOT performing TAVR, and 50% other recommendations.
Lower LOS than national mean
All TAVR patients alive at one year, 75% had rehab.
(Damier et al Ann Cardiol Angeiol (Paris) 2016)
TAVR – “Geriatric” Outcome Predictors - Recap
Frailty and individual criteria
Gait speed
Sarcopenia
Malnutrition
Mood
Functional impairment
Geriatric assessments
Cognition?
When to involve the geriatrician?
(Lilamand et al. Int J Cardiol. 2014)
Components of a preoperative geriatric assessment in TAVR
Reassess symptoms and confirm cardiac etiology
Assess comorbidities to optimize management
Perform CGA, including measures of frailty, function, cognition, mood, nutrition, social context
If possible prognosticate on life expectancy
Clarifying goals of care
Make recommendations
Whether or not to proceed (under which reserves)
How to proceed to minimize complications
On how to optimize management of other conditions
(Otto et al. JACC. 2017)
Potential areas where geriatric expertise may be beneficial
Preoperatively
Patient selection
Optimization (Delirium prevention, medication review, prehab?, control of comorbid diseases, etc.)
Perioperatively
Preventing delirium and other complications, advise on benefits of rehab.
Post-operatively
Accompany in rehab process, manage long term care of complex cases
If no surgery
Palliative care
Higher levels
Involvement in research and program development
Teaching
TAVR – What`s in the loop
Back to 2009
Actually 2010, 3 months before patient`s 100th birthday
Acute CHFE requiring hospitalization
Patient demanded BiPap while attempts at diuresis
Continued to worsen and passed away, without his letter from the Queen…
Juan Gris, 1887
Questions/Comments
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