Author + information
- Received April 18, 2018
- Revision received June 18, 2018
- Accepted June 18, 2018
- Published online November 5, 2018.
- Laura M. Drudi, MD, MSca,b,
- Matthew Ades, MDa,c,
- Anita Asgar, MD, MScd,
- Louis Perrault, MDe,
- Sandra Lauck, RN, PhDf,
- John G. Webb, MDf,
- Andrew Rassi, MDg,
- Andre Lamy, MDh,
- Nicolas Noiseux, MD, PhDi,
- Mark D. Peterson, MDj,
- Marino Labinaz, MDk,
- Thierry Lefèvre, MDl,
- Jeffrey J. Popma, MDm,
- Dae H. Kim, MD, MScn,
- Giuseppe Martucci, MDo,
- Nicolo Piazza, MD, PhDo and
- Jonathan Afilalo, MD, MSca,p,∗ ()
- aDivisions of Cardiology & Clinical Epidemiology, Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, Quebec, Canada
- bDivision of Vascular Surgery, McGill University, Montreal, Quebec, Canada
- cDivision of Internal Medicine, McGill University, Montreal, Quebec, Canada
- dDivision of Cardiology, Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
- eDivision of Cardiac Surgery, Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
- fCentre for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
- gDepartment of Cardiology, Kaiser Permanente - San Francisco Medical Center, San Francisco, California
- hDivision of Cardiac Surgery, Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- iDivision of Cardiac Surgery, Centre Hospitalier de l’Université de Montréal, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- jDivision of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- kDivision of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- lDivision of Interventional Cardiology, Institut cardiovasculaire Paris Sud, Ramsay-générale de santé, Hôpital privé Jacques Cartier, Massy, France
- mDivision of Cardiology, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts
- nDivision of Gerontology, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts
- oDivision of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
- pDivision of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
- ↵∗Address for correspondence:
Dr. Jonathan Afilalo, Divisions of Cardiology & Clinical Epidemiology, Jewish General Hospital, 3755 Cote Ste Catherine Road, E-222, Montreal, Quebec H3T 1E2, Canada.
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.
Dr. Drudi was supported by grants from the Canadian Institutes of Health Research (CIHR) Canada Graduate Scholarships, and Fonds de recherche du Québec- Santé (FRQS) Master’s Grant. Dr. Afilalo was supported by grants for the FRAILTY-AVR Study through an Operating Grant from the Canadian Institutes for Health Research (CIHR), a Clinical Research Scholars Award from the Fonds de Recherche du Québec en Santé (FRQ-S), and a Research Fellowship Award from the Heart and Stroke Foundation of Canada. Dr. Asgar has been a consultant for Edwards Lifesciences and Medtronic. Dr. Perrault has been a consultant for Somahlution; and served on an advisory board for Clearflow. Dr. Lauck has been a consultant for Edwards Lifesciences. Dr. Webb has been a consultant for Edwards Lifesciences and Abbott Vascular. Dr. Peterson has been a proctor for Edwards Lifesciences; and a consultant for LivaNova. Dr. Lefèvre has been a proctor for Edwards Lifesciences and Abbott Vascular. Dr. Popma has received institutional grants from Medtronic, Boston Scientific, Abbott Vascular, and Edwards Lifesciences; and has served on advisory boards for Boston Scientific and Edwards Lifesciences. Dr. Kim has been a consultant for Alosa Health (a nonprofit organization). Dr. Martucci has been a proctor and consultant for Boston Scientific and Medtronic. Dr. Piazza has been a consultant for Highlife, Microport, Boston Scientific, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 18, 2018.
- Revision received June 18, 2018.
- Accepted June 18, 2018.
- 2018 American College of Cardiology Foundation
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