Author + information
- Received April 18, 2018
- Revision received June 18, 2018
- Accepted June 18, 2018
- Published online October 17, 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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