L’ÉVALUATION  GÉRIATRIQUE    

AVANT  TAVI  

Dr  Sophie  DUC  

Dr  Aurélie  LAFARGUE  

2  

→   Rétrécissement  aor/que  =  LA  valvulopathie  de  la  personne  âgée  en  France  

→ OR  popula/on  française  vieillissante  +++  

QUESTION  DE  LA  PRISE  EN  CHARGE  DE  LA  PERSONNE  AGEE  

PORTEUSE  D’UN  RETRECISSEMENT  AORTIQUE  SERRE  

SYMPTOMATIQUE  ?    3  

80  ans  =  6  %  de  la  popula/on  en  01/2016  

(INSEE)  

RÉTRÉCISSEMENT  AORTIQUE  &  PERSONNE  ÂGÉE    

3  %  chez  les  75  ans  

>  10  %  chez  les  ≥  80  ans  

4  

•  Origine  dégénéra/ve  >>>  origine  rhuma/smale  >>  origine  malforma/ve  

•  Longtemps  asymptomaSque  

Appari/on  symptômes  =  stade  avancé  de  la  maladie  

symptômes   espérance  de  vie  esSmée  

douleurs  thoraciques   5  ans  

syncopes     3  ans  

insuffisance  cardiaque   2  ans  

RÉTRÉCISSEMENT  AORTIQUE  &  PERSONNE  ÂGÉE    

5  

Procédure  longue,  

convalescence  par  

la  suite  

Perte  d’indépendance  

fonc/onnelle,  symptômes  

de  +  en  +  fréquents  

Remplacement  

valvulaire  par  chirurgie    

Prise  en  charge  

médicamenteuse  

symptomaSque  

RÉTRÉCISSEMENT  AORTIQUE  SERRÉ  SYMPTOMATIQUE  

CONTRE  INDICATION(S)    

Remplacement  

valvulaire  par  TAVI  (2007)  

Procédure  courte,  

améliora/on  rapide  des  

symptômes,  pas  de  

convalescence  

RÉTRÉCISSEMENT  AORTIQUE  &  TRAITEMENTS  

30  à  40  %  des  pa/ents  

seraient  CI  à  la  chirurgie  

6  

•  Les  contre  indicaSons  absolues    (HAS  +  société  européenne  de  cardiologie)  

RÉTRÉCISSEMENT  AORTIQUE  ,  PERSONNES  ÂGÉES  &  TAVI    

QUI  TRAITER  ?    

 VERITABLE  CASSE  TETE    

1.  Espérance  de  vie  es/mée  <  1  an  

2.  Refus  du  pa/ent  

3.  Thrombus  ou  végéta/on  intracardiaque    

•  Dilemme  de  la  personne  âgée  pour  les  équipes  de  cardiologie  

FRAGILITE    

dépistage  

men/onné  

Comment  ?  

Quand  ?  

 Par  qui  ?    

RÉTRÉCISSEMENT  AORTIQUE  ,  PERSONNES  ÂGÉES  &  TAVI    

•  HAS  et  recommandaSons  européennes  place  du  gériatre  dans  la  «  Heart  Team  »  fortement  recommandée  

7  

8  

COMMENT  DÉPISTER  LA  FRAGILITÉ  ?    

•  RecommandaSons  NICE  2016  

o  Critères  de  Fried  

o  G8  

o  VES-­‐13  (Vulnerable  Elderly  Survey)  

o  Timed  Up  and  Go  Test  

o  Grip  strength  

Multimorbidity: clinical assessment andMultimorbidity: clinical assessment andmanagementmanagement

NICE guideline

Published: 21 September 2016nice.org.uk/guidance/ng56

© NICE 2016. All rights reserved.

Multimorbidity: clinical assessment andMultimorbidity: clinical assessment andmanagementmanagement

NICE guideline

Published: 21 September 2016nice.org.uk/guidance/ng56

© NICE 2016. All rights reserved.

Si  dépistage  posiSf    

Demande  d’une  

Evalua/on  Gériatrique  

Standardisée  (EGS)  

Gold  Standard  

Evalua/on  

mul/dimensionnelle  

Iden/fica/on  et  correc/ons  de  

facteurs  poten/ellement  

modifiables  

9  

POURQUOI  DÉPISTER  LA  FRAGILITÉ  DANS  LES  SERVICES  DE  CARDIOLOGIE  ?    

o  Prévalence  chez  les  pa/ents  insuffisants  cardiaques  hospitalisés  :    74  %  

o  Prévalence  de  pré  fragiles  :  19  %  *  

*  Sheila  M.  McNallan  JACC.  Heart  Failure  1,  no  2  (avril  2013):  135-­‐41  **Dana  H.  Lee  et  al.,  CirculaBon  121,  no  8  (2  mars  2010):  973-­‐78    

92  %  recours  aux  urgences  chez  les  fragiles  

Hospitalisa/on  non  liée  à  la  pathologie  CV  dans  plus  de  la  moi/é  des  cas  

o  Lee  2010  :  étude  chez  les  ≥  75  ans  éligibles  à  une  chirurgie  cardiaque    

Si  présence  en  pré  opératoire  d’une  

aneinte  des  ADL  ou  des  troubles  cogni/fs  

ou  une  incapacité  à  se  mouvoir  seul  

           mortalité  hospitalière  :  OR  =  1,8  

           entrée  en  EHPAD  :  OR  =    6,3  

10  

Evaluation of Multidimensional GeriatricAssessment as a Predictor of Mortality andCardiovascular Events After TranscatheterAortic Valve ImplantationStefan Stortecky, MD,* Andreas W. Schoenenberger, MD,† André Moser, PHD,‡Bindu Kalesan, PHD,‡ Peter Jüni, MD,‡ Thierry Carrel, MD,§ Seraina Bischoff, RN,*Christa-Maria Schoenenberger, RN,* Andreas E. Stuck, MD,† Stephan Windecker, MD,*Peter Wenaweser, MD*

Bern, Switzerland

Objectives This study evaluated Multidimensional Geriatric Assessment (MGA) as predictor of mor-tality and major adverse cardiovascular and cerebral events (MACCE) after transcatheter aortic valveimplantation (TAVI).

Background Currently used global risk scores do not reliably estimate mortality and MACCE inthese patients.

Methods This prospective cohort comprised 100 consecutive patients !70 years undergoing TAVI.Global risk scores (Society of Thoracic Surgeons [STS] score, EuroSCORE) and MGA-based scores(cognition, nutrition, mobility, activities of daily living [ADL], and frailty index) were evaluated aspredictors of all-cause mortality and MACCE 30 days and 1 year after TAVI in regression models.

Results In univariable analyses, all predictors were significantly associated with mortality andMACCE at 30 days and 1 year, except for the EuroSCORE at 30 days and instrumental ADL at 30days and 1 year. Associations of cognitive impairment (odds ratio [OR]: 2.98, 95% confidence interval[CI]: 1.07 to 8.31), malnutrition (OR: 6.72, 95% CI: 2.04 to 22.17), mobility impairment (OR: 6.65, 95%CI: 2.15 to 20.52), limitations in basic ADL (OR: 3.63, 95% CI: 1.29 to 10.23), and frailty index (OR:3.68, 95% CI: 1.21 to 11.19) with 1-year mortality were similar compared with STS score (OR: 5.47,95% CI: 1.48 to 20.22) and EuroSCORE (OR: 4.02, 95% CI: 0.86 to 18.70). Similar results were foundfor 30-day mortality and MACCE. Bivariable analyses, including STS score or EuroSCORE suggestedindependent associations of MGA-based scores (e.g., OR of frailty index: 3.29, 95% CI: 1.06 to 10.15,for 1-year mortality in a model including EuroSCORE).

Conclusions This study provides evidence that risk prediction can be improved by adding MGA-based information to global risk scores. Larger studies are needed for the development and valida-tion of improved risk prediction models. (J Am Coll Cardiol Intv 2012;5:489–96) © 2012 by theAmerican College of Cardiology Foundation

From the *Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland; †Divisionof Geriatrics, Department of General Internal Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern,Switzerland; ‡Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; and the §Department ofCardiovascular Surgery, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland. This study was supportedby research grants from Bern University Hospital and a grant of the Swiss National Science Foundation to Dr. Windecker (SNFGrant 32003B_135807). Dr. Juni is an unpaid member of steering group or executive committee of trials funded by AbbottVascular, Biosensors, Medtronic, and St. Jude Medical. Dr. Windecker received lecture and consulting fees from Medtronic andEdwards Lifesciences. Dr. Wenaweser is a proctor for Medtronic CoreValve and Edwards Lifesciences; and he received honorariafrom Medtronic and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contentsof this paper to disclose. Drs. Stortecky and Schoenenbeger contributed equally to this work. Peter Block, MD, served as a GuestEditor for this paper.

Manuscript received September 9, 2011; revised manuscript received January 27, 2012, accepted February 1, 2012.

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 5 , N O . 5 , 2 0 1 2

© 2 0 1 2 B Y T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N D A T I O N I S S N 1 9 3 6 - 8 7 9 8 / $ 3 6 . 0 0

P U B L I S H E D B Y E L S E V I E R I N C . D O I : 1 0 . 1 0 1 6 / j . j c i n . 2 0 1 2 . 0 2 . 0 1 2

Until recently, 2 treatment options for patients with symp-tomatic severe aortic stenosis were available: surgical aorticvalve replacement (SAVR) and medical treatment, the latteroption with less favorable outcomes as compared withSAVR (1). However, SAVR is frequently not performed inpatients with high operative risk, mainly elderly patientswith comorbid conditions (2,3). Recently, transcatheteraortic valve implantation (TAVI) has been introduced as an

See page 497

alternative, less invasive treatment option and has beenshown to reduce mortality compared with medical treat-ment in patients deemed inoperable (4). Therefore, TAVI

offers a promising alternative toconservative treatment for severeaortic stenosis of elderly, inoper-able patients.

Currently, the risk for cardio-surgical procedures is usually es-timated using Society of Tho-racic Surgeons (STS) scoreand/or logistic EuroSCORE(5). Recently, these global riskscores have been deemed subop-timal for the risk assessment ofelderly patients with aortic stenosis(6–9). There are 3 main reasons:first, these scores were mainlyderived in adults undergoingcardiovascular surgery; second,organ-specific (e.g., cardiac-related) risk predictors are prob-ably under-represented in thesescores; third, specific geriatricconditions that are not measuredby these scores may have a majorimpact on prognosis in elderlypatients. Multidimensional Ge-riatric Assessment (MGA) is a

diagnostic process intended to determine an older person’smedical and functional resources and problems (10). MGAconsists of several components, some of which assess cognitiveand functional capacity. Components of MGA have proventheir usefulness for risk prediction in elderly patients with acutemedical illness (11–14). Only a few studies have hithertoevaluated measures from MGA for the prediction of surgicaloutcomes and found a significant predictive ability (15–20). Sofar, there is no study having assessed MGA-based scores toestimate risk related to TAVI. The present study, therefore,evaluated MGA-based scores as predictors of mortality andmajor adverse cardiovascular and cerebral events (MACCE) inpatients undergoing TAVI.

Methods

Study population. Consecutive patients !70 years withsevere symptomatic aortic stenosis and referred for anin-hospital evaluation for TAVI to Bern University Hospi-tal, Switzerland, between September 1, 2009 and December31, 2010, were eligible for this study. Aortic stenosis wasconsidered severe if the effective orifice area was !1 cm2

and/or !0.6 cm2/m2 body surface area. An interdisciplinaryteam of interventional cardiologists and cardiac surgeonsreviewed the individual cases and formed a consensus ontreatment selection (TAVI, SAVR, or medical treatment).The consensus was based on several parameters, includinganatomic characteristics of the aortic root, vascular accesssite specifications, perioperative risk as calculated with thelogistic EuroSCORE and the STS score, underlying co-morbidities (previous cardiac surgery, pulmonary insuffi-ciency, liver cirrhosis, severe connective tissue disease, his-tory of mediastinal radiotherapy, porcelain aorta), andgeneral impression. Patients with a logistic EuroSCORE!5% were advised to undergo SAVR or medical treatment.The treatment was either selected during the in-hospitalevaluation phase or in the following 1 to 2 weeks afterevaluation. The following patients were excluded: 1) pa-tients with a treatment other than TAVI (i.e., SAVR ormedical treatment); 2) patients who lived abroad and werenot able to participate in the follow-up; and 3) patients inwhom TAVI was performed as an emergency procedure(Fig. 1). All other patients were asked for study participa-tion. If they gave informed consent, MGA was performed.Of the patients who received MGA during the study period,the following were also excluded: 1) patients who stillwaited for TAVI after December 31, 2010; 2) patients whodied before TAVI; 3) patients who crossed over to SAVR ormedical treatment after initial allocation to TAVI; and4) patients in whom the time between MGA and TAVI was"3 months. The final study population consisted of allpatients in whom TAVI and MGA was performed duringthe study period. The cohort study complies with theDeclaration of Helsinki, was approved by the local ethicscommittee, and all patients provided informed writtenconsent.Baseline examinations. All participating patients receivedan extensive cardiologic and geriatric baseline examinationduring the in-hospital evaluation. Patient history was re-corded, including symptoms, cardiovascular risk factors,medication, prior cardiovascular events, and further comor-bidities. Physical examination included the measurement ofweight, height, and blood pressure. Left ventricular ejectionfraction, aortic valve orifice area, and transvalvular meangradient were measured with transthoracic or transesopha-geal echocardiography. All patients underwent cardiac cath-eterization providing information about the presence ofcoronary artery disease and hemodynamic evaluation of

Abbreviationsand Acronyms

BADL ! Basic Activitiesof Daily Living

CI ! confidence interval

IADL ! InstrumentalActivities of Daily Living

MACCE ! major adversecardiovascular and cerebralevents

MGA ! MultidimensionalGeriatric Assessment

MMSE ! Mini MentalState Examination

MNA ! Mini NutritionalAssessment

OR ! odds ratio

SAVR ! surgical aorticvalve replacement

STS ! Society of ThoracicSurgeons

TAVI ! transcatheter aorticvalve implantation

TUG ! Timed Get Upand Go test

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 5 , N O . 5 , 2 0 1 2

M A Y 2 0 1 2 : 4 8 9 – 9 6

Stortecky et al.Geriatric Assessment as Predictor After TAVI

490

Until recently, 2 treatment options for patients with symp-tomatic severe aortic stenosis were available: surgical aorticvalve replacement (SAVR) and medical treatment, the latteroption with less favorable outcomes as compared withSAVR (1). However, SAVR is frequently not performed inpatients with high operative risk, mainly elderly patientswith comorbid conditions (2,3). Recently, transcatheteraortic valve implantation (TAVI) has been introduced as an

See page 497

alternative, less invasive treatment option and has beenshown to reduce mortality compared with medical treat-ment in patients deemed inoperable (4). Therefore, TAVI

offers a promising alternative toconservative treatment for severeaortic stenosis of elderly, inoper-able patients.

Currently, the risk for cardio-surgical procedures is usually es-timated using Society of Tho-racic Surgeons (STS) scoreand/or logistic EuroSCORE(5). Recently, these global riskscores have been deemed subop-timal for the risk assessment ofelderly patients with aortic stenosis(6–9). There are 3 main reasons:first, these scores were mainlyderived in adults undergoingcardiovascular surgery; second,organ-specific (e.g., cardiac-related) risk predictors are prob-ably under-represented in thesescores; third, specific geriatricconditions that are not measuredby these scores may have a majorimpact on prognosis in elderlypatients. Multidimensional Ge-riatric Assessment (MGA) is a

diagnostic process intended to determine an older person’smedical and functional resources and problems (10). MGAconsists of several components, some of which assess cognitiveand functional capacity. Components of MGA have proventheir usefulness for risk prediction in elderly patients with acutemedical illness (11–14). Only a few studies have hithertoevaluated measures from MGA for the prediction of surgicaloutcomes and found a significant predictive ability (15–20). Sofar, there is no study having assessed MGA-based scores toestimate risk related to TAVI. The present study, therefore,evaluated MGA-based scores as predictors of mortality andmajor adverse cardiovascular and cerebral events (MACCE) inpatients undergoing TAVI.

Methods

Study population. Consecutive patients !70 years withsevere symptomatic aortic stenosis and referred for anin-hospital evaluation for TAVI to Bern University Hospi-tal, Switzerland, between September 1, 2009 and December31, 2010, were eligible for this study. Aortic stenosis wasconsidered severe if the effective orifice area was !1 cm2

and/or !0.6 cm2/m2 body surface area. An interdisciplinaryteam of interventional cardiologists and cardiac surgeonsreviewed the individual cases and formed a consensus ontreatment selection (TAVI, SAVR, or medical treatment).The consensus was based on several parameters, includinganatomic characteristics of the aortic root, vascular accesssite specifications, perioperative risk as calculated with thelogistic EuroSCORE and the STS score, underlying co-morbidities (previous cardiac surgery, pulmonary insuffi-ciency, liver cirrhosis, severe connective tissue disease, his-tory of mediastinal radiotherapy, porcelain aorta), andgeneral impression. Patients with a logistic EuroSCORE!5% were advised to undergo SAVR or medical treatment.The treatment was either selected during the in-hospitalevaluation phase or in the following 1 to 2 weeks afterevaluation. The following patients were excluded: 1) pa-tients with a treatment other than TAVI (i.e., SAVR ormedical treatment); 2) patients who lived abroad and werenot able to participate in the follow-up; and 3) patients inwhom TAVI was performed as an emergency procedure(Fig. 1). All other patients were asked for study participa-tion. If they gave informed consent, MGA was performed.Of the patients who received MGA during the study period,the following were also excluded: 1) patients who stillwaited for TAVI after December 31, 2010; 2) patients whodied before TAVI; 3) patients who crossed over to SAVR ormedical treatment after initial allocation to TAVI; and4) patients in whom the time between MGA and TAVI was"3 months. The final study population consisted of allpatients in whom TAVI and MGA was performed duringthe study period. The cohort study complies with theDeclaration of Helsinki, was approved by the local ethicscommittee, and all patients provided informed writtenconsent.Baseline examinations. All participating patients receivedan extensive cardiologic and geriatric baseline examinationduring the in-hospital evaluation. Patient history was re-corded, including symptoms, cardiovascular risk factors,medication, prior cardiovascular events, and further comor-bidities. Physical examination included the measurement ofweight, height, and blood pressure. Left ventricular ejectionfraction, aortic valve orifice area, and transvalvular meangradient were measured with transthoracic or transesopha-geal echocardiography. All patients underwent cardiac cath-eterization providing information about the presence ofcoronary artery disease and hemodynamic evaluation of

Abbreviationsand Acronyms

BADL ! Basic Activitiesof Daily Living

CI ! confidence interval

IADL ! InstrumentalActivities of Daily Living

MACCE ! major adversecardiovascular and cerebralevents

MGA ! MultidimensionalGeriatric Assessment

MMSE ! Mini MentalState Examination

MNA ! Mini NutritionalAssessment

OR ! odds ratio

SAVR ! surgical aorticvalve replacement

STS ! Society of ThoracicSurgeons

TAVI ! transcatheter aorticvalve implantation

TUG ! Timed Get Upand Go test

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 5 , N O . 5 , 2 0 1 2

M A Y 2 0 1 2 : 4 8 9 – 9 6

Stortecky et al.Geriatric Assessment as Predictor After TAVI

490

•  100  pa/ents  ≥  65  A,  suivis  sur  un  an  

•  Facteurs  prédicSfs  de  morbi-­‐mortalité  CV  :  MMSE,  

ADL,  TUG,  MNA  

Survival and predictive factors of mortality after30 days in patients treated with percutaneousimplantation of the CoreValve aortic prosthesisAntonio J. Muñoz-García, MD, PhD, a José M. Hernández-García, MD, PhD, a Manuel F. Jiménez-Navarro, MD, PhD, a

Juan H. Alonso-Briales, MD, a Antonio J. Domínguez-Franco, MD, a Isabel Rodríguez-Bailón, MD, a

María J. Molina-Mora, MD, a Paula Hernández-Rodríguez, MD, b Miguel Such-Martínez, MD, c andEduardo de Teresa-Galván, MD, PhD a Málaga, Spain

Background Few data exist on the clinical impact of transcatheter aortic valve implantation (TAVI) in patients withsymptomatic aortic stenosis and a high surgical risk. The aim of this study was to determine the survival and the factorspredicting mortality after 30 days post-TAVI with the CoreValve prosthesis (Medtronic, Minneapolis, MN).

Methods From April 2008 to October 2010, the CoreValve prosthesis (Medtronic) was implanted in 133 consecutivehigh-risk surgical patients with symptomatic severe aortic stenosis.

Results The mean age was 79.5 ± 6.7 years. The logistic European System for Cardiac Operative Risk Evaluationwas 21.5% ± 14%. The implantation success rate was 97.7%. In-hospital mortality was 4.5%, and the combined end pointof death, vascular complications, myocardial infarction, or stroke had a rate of 9%. Survival at 12 and 24 months was84.5% and 79%, respectively, after a mean follow-up of 11.3 ± 8 months. The New York Heart Association functionalclass improved from 3.3 ± 0.5 to 1.18 ± 0.4 and remained stable at 1 year. A high Charlson index (hazard ratio [HR] 1.44,95% CI 1.09-1.89, P b .01) and a worse Karnofsky score before the procedure (HR 0.95, 95% CI 0.92-0.99, P = .021)were predictors of mortality after 30 days.

Conclusions Transcatheter aortic valve implantation with the CoreValve prosthesis for patients with aortic stenosis and ahigh surgical risk is a safe, efficient option resulting in a medium-term clinical improvement. Survival during follow-up dependson the associated comorbidities. Early mortality beyond 30 days is predicted by preoperative comorbidity scores and thefunctional status of the patient. (Am Heart J 2012;163:288-94.)

The incidence of aortic valve stenosis in developedcountries has risen over recent decades, in associationwith the increase in life expectancy.1 Recent registrieshave shown that 30% to 50% of aortic valve stenosispatients do not undergo surgery for various reasons, suchas advanced age, associated disorders, or a high surgicalrisk.2 Transcatheter aortic valve implantation (TAVI) isnow an accepted alternative in Europe and Canada for

the treatment of patients with severe symptomatic aorticvalve stenosis and a high surgical risk, with high successrates of implantation and low hospital mortality (below10%, according to the early series.3-6 Transcatheteraortic valve implantation has shown superior results tomedical therapy.7

Recent studies have shown an intermediate-termsurvival improvement after TAVI, reaching survivalrates of 81%, 74%, and 61% at 1, 2, and 3 years,respectively, of follow-up.8,9 However, there is a lack ofinformation about the clinical impact of TAVI on qualityof life in older patients with a high surgical risk, about thevarious factors associated with hospital death and latemortality during medium-term follow-up, and aboutwhether these factors could help to better select patientsfor TAVI.The aims of this study were to analyze the outcomes

after percutaneous implantation with the CoreValveaortic prosthesis, determine the short-term survival rate,and identify factors predicting mortality after 30 days.

From the aDepartment of Cardiology, Virgen de la Victoria Clinical University Hospital,Málaga, Spain, bDepartment of Anesthesiology, Virgen de la Victoria Clinical UniversityHospital, Málaga, Spain, and cDepartment of Cardiac Surgery, Virgen de la VictoriaClinical University Hospital, Málaga, Spain.Submitted May 11, 2011; accepted November 17, 2011.Reprint requests: Antonio J. Muñoz-García, MD, PhD, Department of Cardiology Virgende la Victoria Clinical University Hospital, Málaga, Spain Campus de Teatinos s/n 29010Malaga, Spain.E-mail: ajmunozgarcia@secardiologia.es0002-8703/$ - see front matter© 2012, Mosby, Inc. All rights reserved.doi:10.1016/j.ahj.2011.11.013

Material and methodsBetween April 2008 and October 2010, a total of 162 patients

with severe symptomatic aortic valve stenosis and high surgicalrisk were assessed by a multidisciplinary valve team thatincluded clinical cardiologists and cardiac surgeons. Thepatients were referred for possible TAVI using the CoreValveaortic valve prosthesis (Medtronic, Minneapolis, MN). Theselection process of candidate patients for this techniquefollowed the recommendations published by various scientificsocieties10 for the indications and contraindications, and itcomplied with the anatomical criteria necessary for percutane-ous implantation of the CoreValve prosthesis.5,6 All patientsreferred for possible inclusion underwent a clinical evaluation,transthoracic echocardiography, coronary angiography, andangiography of the aortic root and the femoro-iliac axis. Insome cases, computed tomographic evaluation was performed.Written informed consent was obtained in all cases, and thestudy was approved by the hospital institutional review board.

Description of the deviceThe third-generation CoreValve aortic prosthesis was

implanted in all patients. It is a biologic prosthetic trileafletvalve of porcine pericardium, fitted and sutured onto a self-expanding nitinol structure with an 18F release system. Thereare 2 different device sizes available for different annulusdimensions: the 26-mm prosthesis for aortic valve annulus sizesfrom 20 to 23 mm and the 29-mm prosthesis for aortic valveannulus sizes from 23 to 27 mm.

ProcedureMost (96.2%) procedures were performed under local

anesthesia with mild sedation. Access was femoral in 90.9% ofthe cases; the puncture was preclosed with the Prostar XL 10 Fr(Abbot Vascular Devices, Redwood City, CA) percutaneousclosure device. In 12 patients, the subclavian artery access withsurgical cutdown was used (11 left and 1 right) because ofextensive peripheral artery disease of the femoro-iliac vessels.The aortic prosthesis was released under fluoroscopy-guided

angiographic control. Aortography was conducted after implan-tation of the CoreValve prosthesis to quantify the degree ofaortic regurgitation according to the Sellers grade, and a controltransthoracic echocardiogram was performed at 72 hours.

Follow-upAll patients underwent a clinical follow-up, with evaluations

at 30 days and 3, 6, and 12 months, after which they wereevaluated every 6 months. At each visit, data on the New YorkHeart Association (NYHA) functional class, the Barthel qualityof life test, and a surface electrocardiogram were obtained. Atthe 6-month follow-up visit, an echocardiogram was conductedto evaluate the valve function and degree of regurgitation.Plasma N-terminal prohormone B-type natriuretic peptide (NT-proBNP) was measured before the implant procedure and onhospital discharge (normal value b300 pg/mL).

DefinitionsPatients were considered to have a high surgical risk when

there was agreement that valve replacement surgery could beassociated with excess morbidity or mortality, confirmed by a

cardiologist and a cardiac surgeon. The baseline operative risk ofthe patients was estimated by the logistic European System forCardiac Operative Risk Evaluation (EuroSCORE) as well as theSociety of Thoracic Surgeons (STS) score and the presence ofassociated comorbidities. Procedural success was defined as thecorrect implantation and normal function of the aorticprosthesis in the absence of death during the procedure.Mortality, myocardial infarction (MI), stroke, and vascularcomplications were defined according to the Valve AcademicResearch Consortium definitions.11 We also considered the endpoint of hospitalization for symptoms of cardiac or valve-relateddecompensation or hospitalization for noncardiovascular rea-sons at least 30 days after the procedure.A definitive pacemaker was implanted if there was advanced

atrioventricular (AV) block, in accordance with the recommen-dations of the European Society of Cardiology for patients withacquired AV block in special situations.12

The functional status was evaluated using the NYHAclassification. Frailty was defined according to the criteria ofFried et al.13 Comorbidity was established using the Charlsonindex.14 Quality of life for basic daily activities was assessedusing the Barthel index15 and the Karnofsky test.16

Statistical analysisThe data are expressed as the mean ± SD for continuous

variables and as the absolute number and percentage forcategorical variables. A basic descriptive analysis and a Kaplan-Meier survival analysis were performed. The χ2 or Fisher testwas used to compare the qualitative variables or Student t testfor continuous variables, according to their distribution. Amultivariate analysis was performed with a multiple logisticregression model and Cox regression analysis to identifyindependent variables predicting the need for a pacemakerbecause of AV block and to identify the variables correlated withmortality after 30 days, which were performed stepwise toshow more clearly the associations of the various risk factors.This model included those variables that were significant (P b.05) in the univariate analysis or other recognized predictivevariables. The hazard ratio (HR) and the 95% CI were calculatedfrom the parameters estimated with the regression model.Significance was set at P b .05. The data were analyzed withSPSS version 15.0 (SPSS Inc, Chicago, IL).

No extramural funding was used to support this work. Theauthors are solely responsible for the design and conduct of thisstudy, all study analyses, the drafting and editing of the paperand its final contents.

ResultsIn the initial selection process for the candidate patients

for percutaneous treatment, we evaluated 162 patients, ofwhom 143 (88%) were suitable for the percutaneoustechnique; 8 patients were excluded due to anatomicalcontraindications, and 11 patients were excluded forclinical reasons. During the waiting time before treat-ment, 7 patients died and 3 withdrew their consent.Thus, the CoreValve aortic valve prosthesis wasimplanted in 133 patients.

Muñoz-García et al 289American Heart JournalVolume 163, Number 2

Material and methodsBetween April 2008 and October 2010, a total of 162 patients

with severe symptomatic aortic valve stenosis and high surgicalrisk were assessed by a multidisciplinary valve team thatincluded clinical cardiologists and cardiac surgeons. Thepatients were referred for possible TAVI using the CoreValveaortic valve prosthesis (Medtronic, Minneapolis, MN). Theselection process of candidate patients for this techniquefollowed the recommendations published by various scientificsocieties10 for the indications and contraindications, and itcomplied with the anatomical criteria necessary for percutane-ous implantation of the CoreValve prosthesis.5,6 All patientsreferred for possible inclusion underwent a clinical evaluation,transthoracic echocardiography, coronary angiography, andangiography of the aortic root and the femoro-iliac axis. Insome cases, computed tomographic evaluation was performed.Written informed consent was obtained in all cases, and thestudy was approved by the hospital institutional review board.

Description of the deviceThe third-generation CoreValve aortic prosthesis was

implanted in all patients. It is a biologic prosthetic trileafletvalve of porcine pericardium, fitted and sutured onto a self-expanding nitinol structure with an 18F release system. Thereare 2 different device sizes available for different annulusdimensions: the 26-mm prosthesis for aortic valve annulus sizesfrom 20 to 23 mm and the 29-mm prosthesis for aortic valveannulus sizes from 23 to 27 mm.

ProcedureMost (96.2%) procedures were performed under local

anesthesia with mild sedation. Access was femoral in 90.9% ofthe cases; the puncture was preclosed with the Prostar XL 10 Fr(Abbot Vascular Devices, Redwood City, CA) percutaneousclosure device. In 12 patients, the subclavian artery access withsurgical cutdown was used (11 left and 1 right) because ofextensive peripheral artery disease of the femoro-iliac vessels.The aortic prosthesis was released under fluoroscopy-guided

angiographic control. Aortography was conducted after implan-tation of the CoreValve prosthesis to quantify the degree ofaortic regurgitation according to the Sellers grade, and a controltransthoracic echocardiogram was performed at 72 hours.

Follow-upAll patients underwent a clinical follow-up, with evaluations

at 30 days and 3, 6, and 12 months, after which they wereevaluated every 6 months. At each visit, data on the New YorkHeart Association (NYHA) functional class, the Barthel qualityof life test, and a surface electrocardiogram were obtained. Atthe 6-month follow-up visit, an echocardiogram was conductedto evaluate the valve function and degree of regurgitation.Plasma N-terminal prohormone B-type natriuretic peptide (NT-proBNP) was measured before the implant procedure and onhospital discharge (normal value b300 pg/mL).

DefinitionsPatients were considered to have a high surgical risk when

there was agreement that valve replacement surgery could beassociated with excess morbidity or mortality, confirmed by a

cardiologist and a cardiac surgeon. The baseline operative risk ofthe patients was estimated by the logistic European System forCardiac Operative Risk Evaluation (EuroSCORE) as well as theSociety of Thoracic Surgeons (STS) score and the presence ofassociated comorbidities. Procedural success was defined as thecorrect implantation and normal function of the aorticprosthesis in the absence of death during the procedure.Mortality, myocardial infarction (MI), stroke, and vascularcomplications were defined according to the Valve AcademicResearch Consortium definitions.11 We also considered the endpoint of hospitalization for symptoms of cardiac or valve-relateddecompensation or hospitalization for noncardiovascular rea-sons at least 30 days after the procedure.A definitive pacemaker was implanted if there was advanced

atrioventricular (AV) block, in accordance with the recommen-dations of the European Society of Cardiology for patients withacquired AV block in special situations.12

The functional status was evaluated using the NYHAclassification. Frailty was defined according to the criteria ofFried et al.13 Comorbidity was established using the Charlsonindex.14 Quality of life for basic daily activities was assessedusing the Barthel index15 and the Karnofsky test.16

Statistical analysisThe data are expressed as the mean ± SD for continuous

variables and as the absolute number and percentage forcategorical variables. A basic descriptive analysis and a Kaplan-Meier survival analysis were performed. The χ2 or Fisher testwas used to compare the qualitative variables or Student t testfor continuous variables, according to their distribution. Amultivariate analysis was performed with a multiple logisticregression model and Cox regression analysis to identifyindependent variables predicting the need for a pacemakerbecause of AV block and to identify the variables correlated withmortality after 30 days, which were performed stepwise toshow more clearly the associations of the various risk factors.This model included those variables that were significant (P b.05) in the univariate analysis or other recognized predictivevariables. The hazard ratio (HR) and the 95% CI were calculatedfrom the parameters estimated with the regression model.Significance was set at P b .05. The data were analyzed withSPSS version 15.0 (SPSS Inc, Chicago, IL).

No extramural funding was used to support this work. Theauthors are solely responsible for the design and conduct of thisstudy, all study analyses, the drafting and editing of the paperand its final contents.

ResultsIn the initial selection process for the candidate patients

for percutaneous treatment, we evaluated 162 patients, ofwhom 143 (88%) were suitable for the percutaneoustechnique; 8 patients were excluded due to anatomicalcontraindications, and 11 patients were excluded forclinical reasons. During the waiting time before treat-ment, 7 patients died and 3 withdrew their consent.Thus, the CoreValve aortic valve prosthesis wasimplanted in 133 patients.

Muñoz-García et al 289American Heart JournalVolume 163, Number 2

•  133  pa/ents  79  ±  7  ans,  suivi  à  un  mois  et  un  an    

•  Facteurs  prédicSfs  de  morbi-­‐mortalité  CV  à  un  mois  :  

score  de  Charlson  (OR  1,44,  p  <0,01),  score  de  

Karnosfy  (OR  1,5,  p=  0,21)    

POURQUOI  DÉPISTER  LA  FRAGILITÉ  DANS  LES  SERVICES  DE  CARDIOLOGIE  ?    

11  

What is the utility of preoperative frailty assessment for riskstratification in cardiac surgery?

Nigel Mark Bagnall*, Omar Faiz, Ara Darzi and Thanos Athanasiou

Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London, UK

* Corresponding author. Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, Room 1029, 10th Floor QEQM, Paddington,London W2 1NY, UK. Tel: +44-203-3127619; fax: +44-203-3126309; e-mail: nbagnall@imperial.ac.uk (N.M. Bagnall).

Received 22 October 2012; received in revised form 22 March 2013; accepted 12 April 2013

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether frailtyscoring can be used either separately or combined with conventional risk scores to predict survival and complications. Five hundred andthirty-five papers were found using the reported search, of which nine cohort studies represented the best evidence to answer the clinicalquestion. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of thesepapers are tabulated. There is a paucity of evidence, as advanced age is a criterion for exclusion in most randomized controlled trials.Conventional models of risk following cardiac surgery are not calibrated to accurately predict the outcomes in the elderly and do not cur-rently include frailty parameters. There is no universally accepted definition for frailty, but it is described as a physiological decline in mul-tiple organ systems, decreasing a patient’s capacity to withstand the stresses of surgery and disease. Frailty is manifest clinically as deficitsin functional capacity, such as slow ambulation and impairments in the activities of daily living (ADL). Analysis of predictive models usingarea under receiver operating curves (AUC) suggested only a modest benefit by adding gait speed to a Society of Thoracic Surgeons (STSscore)-Predicted Risk of Mortality or Major Morbidity (PROM) risk score (AUC 0.04 mean difference). However, a specialist frailty assess-ment tool named FORECAST was found to be superior at predicting adverse outcomes at 1 year compared with either EuroSCORE or STSscore (AUC 0.09 mean difference). However, risk models incorporating frailty parameters require further validation and have not beenwidely adopted. Routine collection of objective frailty measures such as 5-metre walk time and ADL assessment will help to provide datato develop new risk-assessment models to facilitate risk stratification and clinical decision-making in elderly patients. Based on the bestevidence currently available, we conclude that frailty is an independent predictor of adverse outcome following cardiac surgery or trans-catheter aortic valve implantation, increasing the risk of mortality 2- to 4-fold compared with non-frail patients.

Keywords: Review • Elderly • Cardiac surgery • Frailty • Outcome

INTRODUCTION

A best evidence topic was constructed according to a structuredprotocol. This is fully described in the ICVTS [1].

THREE-PART QUESTION

In patients [undergoing cardiac procedures] what is the [utility ofpreoperative frailty assessments] to [predict survival and compli-cations]?

CLINICAL SCENARIO

You review an 80-year old man with critical aortic stenosis to de-termine whether to recommend aortic valve replacement (AVR)or transcatheter aortic valve implantation (TAVI). His left ventricu-lar ejection fraction is 34%. He has had congestive cardiac failure(New York Heart Association Grade 2), moderate pulmonaryhypertension, chronic kidney disease (glomerular filtration rate

46 ml/min/1.73 m2), mild cognitive impairment and depressionsince his wife died 18 months ago. He lives alone in a ground-floor flat and performs his own personal grooming, but carersassist with household chores. His body mass index is 18.2. Hereports a fair quality of life, walking inside his home with a stickand ventures outside with the assistance of his daughter. You cal-culate his predicted mortality: EuroSCORE = 8.61%, EuroSCOREII = 4.66% and Society of Thoracic Surgeons (STS) risk = 11.9%.However, you are unsure how frailty may alter his periproceduralrisks, and therefore you research the best available evidence onthis topic.

SEARCH STRATEGY

Medline from 1948 to January 2013 was interrogated usingPubMed interface with the following terms: (‘frail’, ‘frailty’, ‘de-pendence’, ‘vulnerable’, ‘decline’) AND (‘aged’*, ‘aged’, ‘elderly’,‘geriatric’) AND (‘risk assessment’*, ‘risk’) AND (‘cardiac surgery’,‘cardiac’ AND ‘surgery’, ‘cardiac surgical procedures’*, ‘aorticvalve’*, (‘transcatheter’ AND ‘aortic valve’)). MeSH terms are

© The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Interactive CardioVascular and Thoracic Surgery 17 (2013) 398–402 BEST EVIDENCE TOPIC – ADULT CARDIACdoi:10.1093/icvts/ivt197 Advance Access publication 10 May 2013

Table 1: Best evidence papers

Author, date, journaland countryStudy type(level of evidence:USPSTFQR score)

Patient group Outcomes Key results Comments

Afilalo et al. (2010),J Am Coll Cardiol,USA/Canada [4]

Multicentre prospectivecohort study(fair quality)

131 patients aged 70 or olderundergoing elective CABG and/or valve replacement/repair

Mean age 75.8 ± 4.4 yearsM:F–87:44

Frailty defined by slow walkingspeed <6 m in 5 s (n = 60)

Fit by normal walking speed>6 m in 5 s (n = 71)

Composite30-day mortalityor majormorbidity

Slow gait increase risk

9 of 71 fit vs 21 of 60 frail(P = 0.002)

OR 3.17 (95% CI 1.17–8.59)

AUC 0.74 (0.64–0.84) STS scorewith gait speed added vs 0.7(0.6–0.8) STS alone; IDI 5%(95% CI 1–8%)

There was no correlation betweengait speed and STS score,suggesting that these wererepresenting distinct domains

Slow gait speed conferred a 2- to3-fold increase in risk for any levelof STS-predicted mortality or majormorbidity compared with normalgait speed

30-day mortality 1 of 71 fit vs 6 of 60 frail(P = 0.047)

Length of stay(still in hospital at14 days)

13 of 71 fit vs 21 of 60 frail(P = 0.03)

Institutionaldischarge

14 of 71 fit vs 25 of 60 frail(P < 0.0001)

Afilalo et al. (2012),Circ Cardiovasc QualOutcomes,USA/Canada [5]

Multicentre prospectivecohort study(poor quality)

152 patients aged 70 or olderundergoing elective CABG and/or valve replacement/repair

Mean age 75.9 ± 4.4 yearsM:F–100:52

Frailty scales (1) CHS scale: gaitspeed, handgrip, inactivity,exhaustion, weight loss; (2) CHSscale with cognitive impairmentand depression; (3) gait speed,handgrip, inactivity, cognitiveimpairment; (4) gait speed alone

Disability scales: (1) Katz ADLscale, (2) IADL, (3) Nagi scale:pushing heavy object, benching,arm raising, picking up smallobjects, lifting >5 kg, walking upstairs, walking 1 mile

Composite30-day mortalityor majormorbidity

Gait speed (frailty) + Nagi score(disability) score + Parsonnet(cardiac) vs Parsonnet alone

AUC = 0.76 vs 0.72 (IDI 2%;95% CI 0–5%)

Frailty and disability parameterswhen combined with cardiac riskscores increase the predictivepower of major morbidity ormortality

Lee et al. (2010),Circulation,Canada [6]

Single-centre retro-spective cohort study(clinical database linkedto provincialadministrative database)(good quality)

3826 patients undergoingelective cardiac surgery(n = 157 frail)

Median age in non-frail 66(IQR 57–74) vs 71 (IQR 61–78)yearsM:F—2828:998

Frailty defined as anyimpairment in ADL, ambulationor diagnosis of dementia

In-hospitalmortality

164 of 3826 fit vs 23 of 157 frail(P < 0.0001)

OR 1.8 [95% CI 1.1–3] (P = 0.03)

Patients with either impairments ofADL, ambulation or dementia havehigher mortality and need forinstitutional discharge

This study did not compare frailtywith conventional cardiac riskscores, and included patientsyounger than 65 years old

Mid-termmortality(1.8 years medianfollow-up)

330 of 3826 fit vs 41 of 157 frail(P < 0.0001)

HR 1.5 [95% CI 1.1–2.2](P = 0.01)

Institutionaldischarge

1316 of 3826 fit vs 65 of 157 frail(P < 0.0001)

OR 6.3 [95% CI 4.2–9.4](P = 0.0001)

Continued

BEST

EVID

ENCE

TOPIC

N. Bagnall et al. / Interactive CardioVascular and Thoracic Surgery 399

What is the utility of preoperative frailty assessment for riskstratification in cardiac surgery?

Nigel Mark Bagnall*, Omar Faiz, Ara Darzi and Thanos Athanasiou

Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London, UK

* Corresponding author. Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, Room 1029, 10th Floor QEQM, Paddington,London W2 1NY, UK. Tel: +44-203-3127619; fax: +44-203-3126309; e-mail: nbagnall@imperial.ac.uk (N.M. Bagnall).

Received 22 October 2012; received in revised form 22 March 2013; accepted 12 April 2013

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether frailtyscoring can be used either separately or combined with conventional risk scores to predict survival and complications. Five hundred andthirty-five papers were found using the reported search, of which nine cohort studies represented the best evidence to answer the clinicalquestion. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of thesepapers are tabulated. There is a paucity of evidence, as advanced age is a criterion for exclusion in most randomized controlled trials.Conventional models of risk following cardiac surgery are not calibrated to accurately predict the outcomes in the elderly and do not cur-rently include frailty parameters. There is no universally accepted definition for frailty, but it is described as a physiological decline in mul-tiple organ systems, decreasing a patient’s capacity to withstand the stresses of surgery and disease. Frailty is manifest clinically as deficitsin functional capacity, such as slow ambulation and impairments in the activities of daily living (ADL). Analysis of predictive models usingarea under receiver operating curves (AUC) suggested only a modest benefit by adding gait speed to a Society of Thoracic Surgeons (STSscore)-Predicted Risk of Mortality or Major Morbidity (PROM) risk score (AUC 0.04 mean difference). However, a specialist frailty assess-ment tool named FORECAST was found to be superior at predicting adverse outcomes at 1 year compared with either EuroSCORE or STSscore (AUC 0.09 mean difference). However, risk models incorporating frailty parameters require further validation and have not beenwidely adopted. Routine collection of objective frailty measures such as 5-metre walk time and ADL assessment will help to provide datato develop new risk-assessment models to facilitate risk stratification and clinical decision-making in elderly patients. Based on the bestevidence currently available, we conclude that frailty is an independent predictor of adverse outcome following cardiac surgery or trans-catheter aortic valve implantation, increasing the risk of mortality 2- to 4-fold compared with non-frail patients.

Keywords: Review • Elderly • Cardiac surgery • Frailty • Outcome

INTRODUCTION

A best evidence topic was constructed according to a structuredprotocol. This is fully described in the ICVTS [1].

THREE-PART QUESTION

In patients [undergoing cardiac procedures] what is the [utility ofpreoperative frailty assessments] to [predict survival and compli-cations]?

CLINICAL SCENARIO

You review an 80-year old man with critical aortic stenosis to de-termine whether to recommend aortic valve replacement (AVR)or transcatheter aortic valve implantation (TAVI). His left ventricu-lar ejection fraction is 34%. He has had congestive cardiac failure(New York Heart Association Grade 2), moderate pulmonaryhypertension, chronic kidney disease (glomerular filtration rate

46 ml/min/1.73 m2), mild cognitive impairment and depressionsince his wife died 18 months ago. He lives alone in a ground-floor flat and performs his own personal grooming, but carersassist with household chores. His body mass index is 18.2. Hereports a fair quality of life, walking inside his home with a stickand ventures outside with the assistance of his daughter. You cal-culate his predicted mortality: EuroSCORE = 8.61%, EuroSCOREII = 4.66% and Society of Thoracic Surgeons (STS) risk = 11.9%.However, you are unsure how frailty may alter his periproceduralrisks, and therefore you research the best available evidence onthis topic.

SEARCH STRATEGY

Medline from 1948 to January 2013 was interrogated usingPubMed interface with the following terms: (‘frail’, ‘frailty’, ‘de-pendence’, ‘vulnerable’, ‘decline’) AND (‘aged’*, ‘aged’, ‘elderly’,‘geriatric’) AND (‘risk assessment’*, ‘risk’) AND (‘cardiac surgery’,‘cardiac’ AND ‘surgery’, ‘cardiac surgical procedures’*, ‘aorticvalve’*, (‘transcatheter’ AND ‘aortic valve’)). MeSH terms are

© The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Interactive CardioVascular and Thoracic Surgery 17 (2013) 398–402 BEST EVIDENCE TOPIC – ADULT CARDIACdoi:10.1093/icvts/ivt197 Advance Access publication 10 May 2013

•  Revue  linérature  

•  Facteurs  prédicSfs  gériatriques  associés  à  une  morbi-­‐

mortalité  post  opératoire  :  ADL,  vitesse  de  marche  

Frailty assessment in thoracic surgeryMichael John Dunne*, Udo Abah and Marco Scarci

Department of Cardio-thoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK

* Corresponding author. Department of Cardiac Surgery, Papworth Hospital, Papworth Everard, Cambridge CB23 3RE, UK. Tel: +44-1480-364474;fax: +44-1480-364740; e-mail: mikedunne@doctors.org.uk (M.J. Dunne).

Received 11 July 2013; received in revised form 12 November 2013; accepted 11 December 2013

Abstract

A best evidence topic in thoracic surgery was performed according to a structured protocol. The question addressed was the role of frailtyscores in predicting outcomes of patients undergoing thoracic surgery. Seventy-one papers were found using the reported search, of whichthree studies and one conference abstract represented the best evidence to answer the clinical question. The authors, journal date, country ofpublication, patient group, study type, relevant outcomes and results are tabulated. Despite an extensive literature search, few studies wereidentified which addressed the clinical dilemma posed, all of which were retrospective observational series. A study analysed 971 434 patientsacross a wide range of surgical specialties, 4648 of which were classified as thoracic. A statistically significant relationship was demonstratedbetween increasing frailty and higher rates of postoperative complications and mortality (P < 0.0001). Another study reported a similar associ-ation between modified frailty index (mFI) scores and postoperative outcomes in patients undergoing lobectomies. Morbidity increased uni-formly with mFI and multivariant analysis found an mFI of >0.27 (P = 0.002) to be an independent predictor of mortality. Another paperdemonstrated higher rates of major postoperative complications and increased mortality (P < 0.001) in patients with higher preoperative de-pendency. A study examined geriatric frailty assessment tools for the prediction of postoperative outcomes in patients over 70 undergoingthoracic surgery for neoplasms. The Geriatric Depression Screen, Mini Mental State Examination, Fatigue Inventory, Eastern Co-OperativeOncology Group Performance Scale and Instrumental Activities of Daily Living were used as a means of determining preoperative frailty.Their conclusion supported the conclusions drawn from the larger studies that a single frailty measure alone did not predict an increase inmorbidity or mortality, but in combination several measures may have a role in predicting postoperative outcomes. The clinical bottom lineis that there is a paucity of evidence to either fully support or fully refute the use of preoperative frailty scoring as a reliable means of predict-ing morbidity and mortality in thoracic surgery. The evidence presented does however indicate the potentially important clinical role thatfrailty scores may have in the future.

Keywords: Frailty • Frailty index • Thoracic surgery • Risk stratification • Surgical outcomes

INTRODUCTION

A best evidence topic was constructed according to a structuredprotocol. This is fully described in the ICVTS [1].

THREE-PART QUESTION

In [patients undergoing thoracic surgery] do [frailty scores] act as a[good predictor of outcomes].

CLINICAL SCENARIO

In thoracic outpatient clinic, an 84-year old asks you the likelihoodof a good postoperative outcome. Despite their frail appearance,tripartite assessment (incorporating lung function, cardiac riskfactors and Thoracoscore) establishes a low surgical risk. Youremain concerned however that their frailty will impact uponpostoperative recovery. You resolve to determine whether a

method incorporating frailty assessment exists to predict morbid-ity and mortality in these patients.

SEARCH STRATEGY

A search was performed using Medline from 1809 to 2013 via thePubMed interface with the search terms [thoracic surgery, frailtyindex, frailty, elderly, morbidity, mortality, outcomes limited toand human studies].

SEARCH OUTCOME

Seventy papers were found using the reported search. Threepapers and one conference abstract were identified that providedthe best evidence to answer the question (Table 1).

RESULTS

Velanovich et al. [2] hypothesized that preoperative evaluation offrailty (including clinical history, physical examination, physical

© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

BES

TEV

IDEN

CETO

PIC

Interactive CardioVascular and Thoracic Surgery 18 (2014) 667–670 BEST EVIDENCE TOPIC – THORACICdoi:10.1093/icvts/ivt542 Advance Access publication 27 January 2014

Table 1: Best evidence papers

Author, date journal,Study type(level of evidence)

Patient group Outcomes Key results Comments

Velanovich et al.(2013), J Surg Res,USA [2]

Retrospective analysis(level 2b)

Retrospective analysis of 971 434patients undergoing surgery; ofwhich, 4648 were classified ashaving ‘general thoracic surgery’

Modified frailty index

Postoperative complications(morbidity), includingsurgical site infection,empyema, pneumonia,urinary tract infection,reintubation, pulmonaryembolism, failure to weanventilation, renal failure andre-admission to ICU

Mortality

Statistically significantrelationship between a higherfrailty index and increased riskof postoperative morbidity andmortality in mid- tohigh-complexity thoracicoperations [P < 0.0001]

Study showed a significantassociation between a higherpreoperative frailty index andincreased morbidity andmortality

Also suggested that frailtymay have more of an impacton ‘low risk’ operations

Tsiouris et al. (2013), JSurg Res, USA [3]

Retrospective study(level 2b)

Retrospective study of 1940patients who underwentlobectomy. A preoperativemodified frailty index wasderived based on the CHSAindex

Modified frailty index

Postoperative complications(morbidity) including surgicalsite infection, empyema,pneumonia, urinary tractinfection, reintubation,pulmonary embolism, failureto wean ventilation, renalfailure and re-admission toICU

Mortality

A modified frailty index (mFI)>0.27 was associated with a5.6% mortality rate [P = 0.001]

Multivariant analysis showedthat contaminated wounds andan mFI of >0.27 [OR 4, CI 1.07–24, P = 0.045 and OR 9.3, CI9.4–27, P = 0.002, respectively]were the strongest predictors ofmortality

Regressional analysisdemonstrated that an mFI of>0.27 [OR 4.9, CI 95% 1.3–230,P = 0.027], contaminatedwounds [OR 4.8, CI 95% 1.2–53,P = 0.028], ASA grade 4 [OR 6.8,95% CI 1.8–27, P = 0.009] anddependent functional status[OR 4.7 9%, CI 1.2–9.8, P = 0.03]were the main predictors ofmajor complications

The study suggests that use ofan mFI based onpreoperative variables hasthe potential to act as apredictor for morbidity andmortality

Tsiouris et al. (2012), JSurg Res, USA [4]

Retrospective analysis(level 2b)

Retrospective analysis of 6373patients undergoing thoracicsurgery. Preoperative functionalstatus was measured andclassified based on the ability toperform ADLs. Two groups wereproduced; independent andnon-independent (5561 vs 812)

Functional status

Postoperative complications(morbidity) including surgicalsite infection, empyema,pneumonia, urinary tractinfection, reintubation,pulmonary embolism, failureto wean ventilation, renalfailure and re-admission toICU

Mortality

Patients in the ‘dependent’group were found to havehigher rates of postoperativecomplications. In particular,prolonged ventilation was 9.3times more likely [P < 0.001],re-intubation was 3.1 timesmore likely [P < 0.001] andmortality was 7.7 times higher[P < 0.001]

The paper showed thatpatients with preoperativefunctional dependency hadan increased risk of majorpostoperative complicationsas well as increased mortality

Weigel et al. (2013),American Associationfor Thoracic SurgeryConference Abstract,USA [5]

Retrospective audit(level 2c)

Retrospective audit of 79patients over the age of 70undergoing thoracic surgery forneoplasms

Geriatric Depression Screen(GDS), Mini Mental StateExamination (MMSE), FatigueInventory (FI), EasternCo-Operative OncologyGroup Performance Scale(ECOG PS) and assessment ofADLs and InstrumentalActivities of Daily Living(IADLs)

No measured preoperativevariable was able to predictpostoperative outcomes

The authors suggest that acombination of preoperativefrailty measures may bebeneficial in predictingpostoperative morbidity andmortality

M.J. Dunne et al. / Interactive CardioVascular and Thoracic Surgery668

Frailty assessment in thoracic surgeryMichael John Dunne*, Udo Abah and Marco Scarci

Department of Cardio-thoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK

* Corresponding author. Department of Cardiac Surgery, Papworth Hospital, Papworth Everard, Cambridge CB23 3RE, UK. Tel: +44-1480-364474;fax: +44-1480-364740; e-mail: mikedunne@doctors.org.uk (M.J. Dunne).

Received 11 July 2013; received in revised form 12 November 2013; accepted 11 December 2013

Abstract

A best evidence topic in thoracic surgery was performed according to a structured protocol. The question addressed was the role of frailtyscores in predicting outcomes of patients undergoing thoracic surgery. Seventy-one papers were found using the reported search, of whichthree studies and one conference abstract represented the best evidence to answer the clinical question. The authors, journal date, country ofpublication, patient group, study type, relevant outcomes and results are tabulated. Despite an extensive literature search, few studies wereidentified which addressed the clinical dilemma posed, all of which were retrospective observational series. A study analysed 971 434 patientsacross a wide range of surgical specialties, 4648 of which were classified as thoracic. A statistically significant relationship was demonstratedbetween increasing frailty and higher rates of postoperative complications and mortality (P < 0.0001). Another study reported a similar associ-ation between modified frailty index (mFI) scores and postoperative outcomes in patients undergoing lobectomies. Morbidity increased uni-formly with mFI and multivariant analysis found an mFI of >0.27 (P = 0.002) to be an independent predictor of mortality. Another paperdemonstrated higher rates of major postoperative complications and increased mortality (P < 0.001) in patients with higher preoperative de-pendency. A study examined geriatric frailty assessment tools for the prediction of postoperative outcomes in patients over 70 undergoingthoracic surgery for neoplasms. The Geriatric Depression Screen, Mini Mental State Examination, Fatigue Inventory, Eastern Co-OperativeOncology Group Performance Scale and Instrumental Activities of Daily Living were used as a means of determining preoperative frailty.Their conclusion supported the conclusions drawn from the larger studies that a single frailty measure alone did not predict an increase inmorbidity or mortality, but in combination several measures may have a role in predicting postoperative outcomes. The clinical bottom lineis that there is a paucity of evidence to either fully support or fully refute the use of preoperative frailty scoring as a reliable means of predict-ing morbidity and mortality in thoracic surgery. The evidence presented does however indicate the potentially important clinical role thatfrailty scores may have in the future.

Keywords: Frailty • Frailty index • Thoracic surgery • Risk stratification • Surgical outcomes

INTRODUCTION

A best evidence topic was constructed according to a structuredprotocol. This is fully described in the ICVTS [1].

THREE-PART QUESTION

In [patients undergoing thoracic surgery] do [frailty scores] act as a[good predictor of outcomes].

CLINICAL SCENARIO

In thoracic outpatient clinic, an 84-year old asks you the likelihoodof a good postoperative outcome. Despite their frail appearance,tripartite assessment (incorporating lung function, cardiac riskfactors and Thoracoscore) establishes a low surgical risk. Youremain concerned however that their frailty will impact uponpostoperative recovery. You resolve to determine whether a

method incorporating frailty assessment exists to predict morbid-ity and mortality in these patients.

SEARCH STRATEGY

A search was performed using Medline from 1809 to 2013 via thePubMed interface with the search terms [thoracic surgery, frailtyindex, frailty, elderly, morbidity, mortality, outcomes limited toand human studies].

SEARCH OUTCOME

Seventy papers were found using the reported search. Threepapers and one conference abstract were identified that providedthe best evidence to answer the question (Table 1).

RESULTS

Velanovich et al. [2] hypothesized that preoperative evaluation offrailty (including clinical history, physical examination, physical

© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

BES

TEV

IDEN

CETO

PIC

Interactive CardioVascular and Thoracic Surgery 18 (2014) 667–670 BEST EVIDENCE TOPIC – THORACICdoi:10.1093/icvts/ivt542 Advance Access publication 27 January 2014

•  Revue  linérature  

•  Un  seul  paramètre  gériatrique  ne  prédit  en  rien  une  

fragilité  pris  isolément  =>  nécessité  d’une  évaluaSon  

mulSdimensionnelle  pour  une  évaluaSon  globale  et  

précise  de  la  PA  

POURQUOI  DÉPISTER  LA  FRAGILITÉ  DANS  LES  SERVICES  DE  CARDIOLOGIE  ?    

DERNIÈRES  RECOMMANDATIONS  EUROPÉENNES  2017    

ANMCO/SIC/SICI-GISE/SICCH Executive Summary ofConsensus Document on Risk Stratification in elderlypatients with aortic stenosis before surgeryor transcatheter aortic valve replacement

Giovanni Pulignano (Coordinator)1, Michele Massimo Gulizia, FACC, FESC(Coordinator)2, Samuele Baldasseroni3, Francesco Bedogni4, Giovanni Cioffi5,Ciro Indolfi6, Francesco Romeo7, Adriano Murrone8, Francesco Musumeci9,Alessandro Parolari10, Leonardo Patane11, Paolo Giuseppe Pino12,Annalisa Mongiardo6, Carmen Spaccarotella6, Roberto Di Bartolomeo13, andGiuseppe Musumeci14

1Cardiology Department 1, Ospedale San Camillo-Forlanini, Via O. Regnoli, 8 00152 Rome, Italy2Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione“Garibaldi” Catania, Italy3General Cardiology Unit, AOU Careggi, Florence, Italy4CCU-Cardiology Unit, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy5Cardiology and Medicine Unit, Casa di Cura Villa Bianca, Trento, Italy6Cardiology Unit- Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro, Italy7Cardiology and Interventional Cardiology Department, Policlinico “Tor Vergata”, Rome, Italy8Cardiology and Cardiovascular Pathophysiology Department, Azienda Ospedaliera di Perugia, Perugia, Italy9Heart Surgery Department, Ospedale San Camillo-Forlanini, Rome, Italy10Heart Surgery Unit, Centro Cardiologico Monzino IRCCS, Universit!a degli Studi, Milano, Italy11Cardiology Cardiac Surgery Department (Centro Cuore), Centro Clinico Diagnostico G.B. Morgagni, Pedara(Catania), Italy12Cardiology Unit 2, Ospedale San Camillo-Forlanini, Rome, Italy13Heart Surgery Unit, Ospedale Policlinico S. Orsola-Malpighi, Bologna, Italy14Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy

Revised by Roberto Antonicelli, Roberto Caporale, Donatella del Sindaco. SilvioKlugmann, Gennaro Santoro

Consensus Document Approval Faculty in appendix

*Corresponding author. Tel: 0658704562, Email: gipulig@yahoo.it

VC The Author 2017. Published on behalf of the European Society of Cardiology.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium,provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

European Heart Journal Supplements (2017) 19 (Supplement D), D354–D369The Heart of the Matterdoi:10.1093/eurheartj/sux012

ANMCO/SIC/SICI-GISE/SICCH Executive Summary ofConsensus Document on Risk Stratification in elderlypatients with aortic stenosis before surgeryor transcatheter aortic valve replacement

Giovanni Pulignano (Coordinator)1, Michele Massimo Gulizia, FACC, FESC(Coordinator)2, Samuele Baldasseroni3, Francesco Bedogni4, Giovanni Cioffi5,Ciro Indolfi6, Francesco Romeo7, Adriano Murrone8, Francesco Musumeci9,Alessandro Parolari10, Leonardo Patane11, Paolo Giuseppe Pino12,Annalisa Mongiardo6, Carmen Spaccarotella6, Roberto Di Bartolomeo13, andGiuseppe Musumeci14

1Cardiology Department 1, Ospedale San Camillo-Forlanini, Via O. Regnoli, 8 00152 Rome, Italy2Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione“Garibaldi” Catania, Italy3General Cardiology Unit, AOU Careggi, Florence, Italy4CCU-Cardiology Unit, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy5Cardiology and Medicine Unit, Casa di Cura Villa Bianca, Trento, Italy6Cardiology Unit- Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro, Italy7Cardiology and Interventional Cardiology Department, Policlinico “Tor Vergata”, Rome, Italy8Cardiology and Cardiovascular Pathophysiology Department, Azienda Ospedaliera di Perugia, Perugia, Italy9Heart Surgery Department, Ospedale San Camillo-Forlanini, Rome, Italy10Heart Surgery Unit, Centro Cardiologico Monzino IRCCS, Universit!a degli Studi, Milano, Italy11Cardiology Cardiac Surgery Department (Centro Cuore), Centro Clinico Diagnostico G.B. Morgagni, Pedara(Catania), Italy12Cardiology Unit 2, Ospedale San Camillo-Forlanini, Rome, Italy13Heart Surgery Unit, Ospedale Policlinico S. Orsola-Malpighi, Bologna, Italy14Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy

Revised by Roberto Antonicelli, Roberto Caporale, Donatella del Sindaco. SilvioKlugmann, Gennaro Santoro

Consensus Document Approval Faculty in appendix

*Corresponding author. Tel: 0658704562, Email: gipulig@yahoo.it

VC The Author 2017. Published on behalf of the European Society of Cardiology.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium,provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

European Heart Journal Supplements (2017) 19 (Supplement D), D354–D369The Heart of the Matterdoi:10.1093/eurheartj/sux012

Constat  :  TAVI  améliore  les  signes  respiratoires  mais  pas  ou  peu  la  qualité  de  vie  des  

personnes  âgées  et  leur  statut  fonc/onnel  

Pistes  de  réflexion  

1.  Ques/on  du  «  poids  »  des  comorbidités  ?  Comment  s’y  retrouver  ?  

2.  Nécessité  d’avoir  recours  plus  fréquemment  à  une  EGS  pour  dépister  en  

amont  les  éventuels  facteurs  modifiables  et  non  modifiables  

KEYWORDSAortic stenosis;Elderly;TAVI;SAVR;Risk score;Frailty;Prognosis;Geriatric assessment

Aortic stenosis is one of the most frequent valvular diseases in developed countries,and its impact on public health resources and assistance is increasing. A substantialproportion of elderly people with severe aortic stenosis is not eligible to surgery be-cause of the advanced age, frailty, and multiple co-morbidities. Transcatheter aorticvalve implantation (TAVI) enables the treatment of very elderly patients at high orprohibitive surgical risk considered ineligible for surgery and with an acceptable lifeexpectancy. However, a significant percentage of patients die or show no improve-ment in quality of life (QOL) in the follow-up. In the decision-making process, it isimportant to determine: (i) whether and how much frailty of the patient influencesthe risk of procedures; (ii) how the QOL and the individual patient’s survival areinfluenced by aortic valve disease or from other associated conditions; and (iii)whether a geriatric specialist intervention to evaluate and correct frailty or otherdiseases with their potential or already manifest disabilities can improve the out-come of surgery or TAVI. Consequently, in addition to risk stratification with conven-tional tools, a number of factors including multi-morbidity, disability, frailty, andcognitive function should be considered, in order to assess the expected benefit ofboth surgery and TAVI. The pre-operative optimization through a multidisciplinaryapproach with a Heart Team can counteract the multiple damage (cardiac, neuro-logical, muscular, respiratory, and kidney) that can potentially aggravate thereduced physiological reserves characteristic of frailty. The systematic application inclinical practice of multidimensional assessment instruments of frailty and cognitivefunction in the screening and the adoption of specific care pathways should facilitatethis task.

Introduction

Aortic stenosis (AS) is one of the most common acquiredvalvular abnormalities in developed countries, with anincreasing prevalence due to the ageing population.1–3 Theprognosis of AS is relatively benign in the absence of symp-toms; however, an incidence of sudden death between 1%and 3% must be taken into account. The onset of symptomscoincides with a dramatic reduction in life expectancy,with a median survival of 2–3 years in patients with anginaor syncope and only 1–2 years in symptomatic patients withheart failure.3,4

Surgical aortic valve replacement (SAVR) remains thegold standard of care;5 however, at least 40% of potentialpatients are not candidate because of the prohibitive na-ture of their co-morbidities and consequent perioperativerisk.6,7 Consistent with the epidemiological changes, inclinical practice, about three-quarters of patients with iso-lated SAVR receive a bioprosthesis.8 Advanced age alonecannot be considered an obstacle to surgery, but medicaloptions are limited. Elderly patients who do not receive aSAVR have a higher risk of mortality compared with thosetreated surgically.9 Isolated SAVR can be performed in octo-genarians with low post-operative mortality10 and result insignificant improvement in quality of life (QOL), symptoms,and functional capacity.11 In addition, cost-effectivenessanalyses have shown that SAVR is convenient also for veryelderly patients.12

In the last years, transcatheter aortic valve implantation(TAVI) has emerged as a less invasive treatment strategy inhigh-risk patients, allowing the treatment of more com-plex, elderly patients, with severe symptomatic AS, previ-ously considered ineligible for surgery.13–15 However, even

today, a considerable percentage of these patients die ordo not present a significant improvement in dyspnoea, fa-tigue, and functional impairment. This observation hasraised a lively discussion on the need to identify and recog-nize the boundaries of indications for surgical and interven-tional procedures and, consequently, identify a possiblefutility in some patients.16 The decision-making process inthis population is difficult because of co-morbidity, disabil-ity, frailty, and reduced life expectancy, and these factors,as well as traditional ones, should be considered in riskstratification. It is likely that TAVI will be used in an increas-ing number of AS patients, but its exact role alongsidesurgery will need to be defined in a judicious and evidence-based manner. The assessment by a multidisciplinary teamis therefore essential to predict possible benefits and allowto make complex decisions with a clear communication tothe patient. The decision that surgical treatment or withTAVI is useless/futile should include alternative routes tooptimize the patient’s health state and to consider optionsfor assistance to the terminal stages.17

Heterogeneity and complexity

The peculiar feature of the elderly patient can be summar-ized in two words: phenotypic heterogeneity and complex-ity. In these two dimensions describe the effects ofcardiovascular ageing, heart disease, lifestyle, and socio-environmental factors and three different entities: co-morbidity, disability, and frailty (Figure 1).18 Complexityconsiders not only the sum of all coexisting diseases andgeriatric conditions but also their mutual interactions.From a conceptual point of view, therefore, the elderlyperson is in himself/herself a complex patient.

Risk stratification in older patients before aortic valve surgery and TAVI D355

KEYWORDSAortic stenosis;Elderly;TAVI;SAVR;Risk score;Frailty;Prognosis;Geriatric assessment

Aortic stenosis is one of the most frequent valvular diseases in developed countries,and its impact on public health resources and assistance is increasing. A substantialproportion of elderly people with severe aortic stenosis is not eligible to surgery be-cause of the advanced age, frailty, and multiple co-morbidities. Transcatheter aorticvalve implantation (TAVI) enables the treatment of very elderly patients at high orprohibitive surgical risk considered ineligible for surgery and with an acceptable lifeexpectancy. However, a significant percentage of patients die or show no improve-ment in quality of life (QOL) in the follow-up. In the decision-making process, it isimportant to determine: (i) whether and how much frailty of the patient influencesthe risk of procedures; (ii) how the QOL and the individual patient’s survival areinfluenced by aortic valve disease or from other associated conditions; and (iii)whether a geriatric specialist intervention to evaluate and correct frailty or otherdiseases with their potential or already manifest disabilities can improve the out-come of surgery or TAVI. Consequently, in addition to risk stratification with conven-tional tools, a number of factors including multi-morbidity, disability, frailty, andcognitive function should be considered, in order to assess the expected benefit ofboth surgery and TAVI. The pre-operative optimization through a multidisciplinaryapproach with a Heart Team can counteract the multiple damage (cardiac, neuro-logical, muscular, respiratory, and kidney) that can potentially aggravate thereduced physiological reserves characteristic of frailty. The systematic application inclinical practice of multidimensional assessment instruments of frailty and cognitivefunction in the screening and the adoption of specific care pathways should facilitatethis task.

Introduction

Aortic stenosis (AS) is one of the most common acquiredvalvular abnormalities in developed countries, with anincreasing prevalence due to the ageing population.1–3 Theprognosis of AS is relatively benign in the absence of symp-toms; however, an incidence of sudden death between 1%and 3% must be taken into account. The onset of symptomscoincides with a dramatic reduction in life expectancy,with a median survival of 2–3 years in patients with anginaor syncope and only 1–2 years in symptomatic patients withheart failure.3,4

Surgical aortic valve replacement (SAVR) remains thegold standard of care;5 however, at least 40% of potentialpatients are not candidate because of the prohibitive na-ture of their co-morbidities and consequent perioperativerisk.6,7 Consistent with the epidemiological changes, inclinical practice, about three-quarters of patients with iso-lated SAVR receive a bioprosthesis.8 Advanced age alonecannot be considered an obstacle to surgery, but medicaloptions are limited. Elderly patients who do not receive aSAVR have a higher risk of mortality compared with thosetreated surgically.9 Isolated SAVR can be performed in octo-genarians with low post-operative mortality10 and result insignificant improvement in quality of life (QOL), symptoms,and functional capacity.11 In addition, cost-effectivenessanalyses have shown that SAVR is convenient also for veryelderly patients.12

In the last years, transcatheter aortic valve implantation(TAVI) has emerged as a less invasive treatment strategy inhigh-risk patients, allowing the treatment of more com-plex, elderly patients, with severe symptomatic AS, previ-ously considered ineligible for surgery.13–15 However, even

today, a considerable percentage of these patients die ordo not present a significant improvement in dyspnoea, fa-tigue, and functional impairment. This observation hasraised a lively discussion on the need to identify and recog-nize the boundaries of indications for surgical and interven-tional procedures and, consequently, identify a possiblefutility in some patients.16 The decision-making process inthis population is difficult because of co-morbidity, disabil-ity, frailty, and reduced life expectancy, and these factors,as well as traditional ones, should be considered in riskstratification. It is likely that TAVI will be used in an increas-ing number of AS patients, but its exact role alongsidesurgery will need to be defined in a judicious and evidence-based manner. The assessment by a multidisciplinary teamis therefore essential to predict possible benefits and allowto make complex decisions with a clear communication tothe patient. The decision that surgical treatment or withTAVI is useless/futile should include alternative routes tooptimize the patient’s health state and to consider optionsfor assistance to the terminal stages.17

Heterogeneity and complexity

The peculiar feature of the elderly patient can be summar-ized in two words: phenotypic heterogeneity and complex-ity. In these two dimensions describe the effects ofcardiovascular ageing, heart disease, lifestyle, and socio-environmental factors and three different entities: co-morbidity, disability, and frailty (Figure 1).18 Complexityconsiders not only the sum of all coexisting diseases andgeriatric conditions but also their mutual interactions.From a conceptual point of view, therefore, the elderlyperson is in himself/herself a complex patient.

Risk stratification in older patients before aortic valve surgery and TAVI D355

12  

L’EGS  PRÉ-­‐TAVI  CONCRÈTEMENT    

13  

Mr  R.  85  ans   Mme  S.  80  ans  

SOCIAL   Vit  à  domicile  avec  épouse,  pas  d’aide   Vit  à  domicile  avec  époux,  IDE  2/j  

ADL  /IADL   6/6  ;  6/8   2/6  ;  1/8  

COMORBIDITES   5,  aucune  CIRS-­‐G  3/4   4,  dont  2  CIRS-­‐G3  (Irale,  psy)  

POLYMEDICATION   5  médicaments,  1  misuse  IPP   7  médicaments  

COGNITION  ET  THYMIE  

MMSE  25/30  (pas  cert.  d’étude),  pas  de  

no/on  de  confusion  14/30  (directrice  école),antécédents  

de  confusion  

GDS   3/15    3/15  

NUTRITION  

IMC   20  kg/m2   22  kg/m2  

MNA   23/30,  jeûne  nocturne  long   16/30  

FONCTIONNEL  

marche   sans  canne,  légère  rétropulsion   rétropulsion  +,  marche  avec  canne    

relever  de  chaise  5  fois   +   -­‐  

TUG  (secondes)   21   28  

BIOLOGIE   anémie  macrocytaire    isolée   RAS  

SOUHAIT  /  TAVI  ?   comprend  les  risques,  souhaite  le  TAVI  

ne  comprend  pas  les  risques,  s’en  remet  à  son  mari,  indifférente  14  

TAVI  OR  NOT  TAVI  ?  

Mr  R.  85  ans    →  pa/ent  avec  quelques  fragilités  

pouvant  être  modifiées  avec  pec  

adaptée  pré  et  post  TAVI  

→  souhait  du  pa/ent  ++  et  comprend  les  risques    

→  proposi/ons  de  pec  gériatrique  

soumises  à  l’équipe  de  cardiologie  

et  au  médecin  traitant    

Mme  S.  80  ans      →  balance  bénéfices  /risques  défavorable  

→  comorbidités  grêlant  une  morbi-­‐mortalité  

à  1  et  5  ans  

→  pa/ente  distante  de  sa  prise  en  charge    

NOT  TAVI  –  aide  à  la  prise  en  charge  des  

comorbidités  et  de  la  pathologie  cogni/ve  

avancée  ayant  des  répercussions  dans  la  vie  

courante  et  sur  l’aidant  principal    TAVI  –  avec  mise  en  place  d’un  plan  

de  soins  adapté  pré  et  post  TAVI    15  

Problème  dépisté     ProposiSon(s)  

MMSE  25/30   Imagerie  cérébrale  de  principe  avec  prévenSon  si  possible  d’une  confusion  post  TAVI  –  suivi  par  la  suite  avec  équipe  de  gériatrie    

Sur  le  plan  nutriSonnel     Nécessité  d’une  prise  en  charge  avec  diétéScienne  pré  et  post  TAVI:  alimenta/on  hyper  énergé/que,  hyper  protéique  frac/onnée    Dosages  B9/B12  pour  l’anémie  macrocytaire  

Sur  le  plan  foncSonnel     Kinésithérapie  foncSonnelle  pré  TAVI  et  post  TAVI  avec  renforcement  musculaire,  schéma  de  marche,  main/en  des  amplitudes  ar/culaires    Dosage  vitamine  D25    

Sur  le  plan  thérapeuSque   Arrêt  IPP  :  aucune  indica/on    

Sur  le  plan  social   Possibilités  de  mise  en  place  d’aides  humaines  post  TAVI  avec  passage  auxiliaire  de  vie  pour  la  réalisa/on  des  courses,  IDE  (surveillance  du  poids),  kinésithérapeute  

16  

EGS  –  TAVI  -­‐  AQUITAINE  

•  Réseau  AQUITAVI  

•  PHRC  EVAG-­‐TAVI  (Pr.  Belmin)   17  

Contact  mails  des  différents  équipes  

mi  juillet  2017    

Recenser  

1.  Une  ac/vité  d’EGS  pré  TAVI  dans  les  différents  CH  

2.  Les  ou/ls  d’évalua/on  u/lisés  Souhaits    

3.  Mise  en  place  d’un  ou/l  de  

screening  avec  les  équipes  de  

cardiologie  

4.  U/liser  ou/ls  communs  pour  un  

registre  Aquitain  

MERCI  DE  VOTRE  ATTENTION  !  

aurelie.lafargue@chu-­‐bordeaux.fr  

18