TAVR, SAVR outcomes worse in patients with severe frailty

A patient’s degree of frailty could predict their functional outcomes in the year following transcatheter or surgical aortic valve repair (TAVR or SAVR), according to research out of Beth Israel Deaconess Medical Center in Boston.

The study, led by Harvard assistant professor Dae Hyun Kim, MD, MPH, and published in JAMA Internal Medicine Feb. 4, suggests that despite the disease-specific benefits of aortic valve replacement, patients who undergo TAVR or SAVR and are severely frail may still suffer from functional decline or a lack of functional improvement post-intervention.

“Since functional status can be more meaningful than longevity in older adults, information on functional status after the procedure is needed for patient-centered decision-making and perioperative care to improve functional recovery,” Kim and co-authors wrote. “Examining functional trajectories using a generic measure of functional status may offer useful insights that are not captured by disease-specific measures, yet are relevant for patient selection, preventive care and rehabilitation.”

The researchers tracked 246 patients at their institution undergoing TAVR or SAVR for severe aortic stenosis between 2014 and 2017, following up with each via phone interviews at one, three, six, nine and 12 months after their procedure. During check-ins, patients self-reported their ability to perform 22 activities—seven daily living activities, like walking, bathing and getting dressed; seven instrumental activities of daily living, including managing finances and cleaning the house; and eight physical tasks, like writing, lifting a 4.5-kilogram weight or climbing a flight of stairs.

Subjects were categorized into five trajectories based on their functional status at baseline and during follow-up: excellent, good, fair, poor and very poor. In addition, each patient was assigned a calculated comprehensive geriatric assessment-based frailty index (CGA-FI) score, where higher values indicated greater frailty.

Of the nearly 250 patients included in Kim et al.’s study, 143 underwent TAVR and 103 underwent SAVR. After TAVR, the most common trajectory was fair (37.8 percent of patients), followed by good (23.1 percent), poor (14.7 percent), excellent (14 percent) and very poor (8.4 percent). Comparatively, after SAVR, patient trajectories were most commonly good (37.9 percent), excellent (36.9 percent), fair (19.4 percent), poor (2.9 percent) and very poor (1 percent).

There were more positive outcomes in the SAVR cohort, which could be owed to the fact that more TAVR patients were classified as frail before their procedure. After TAVR, patients with a CGA-FI level of 0.20 or lower had excellent (50 percent) or good (50 percent) trajectories, while most patients with a CGA-FI level of 0.51 or higher had poor (45.5 percent) or very poor (22.7 percent) trajectories. Findings were similar in the SAVR group, though fewer of those patients saw poor or very poor outcomes.

“The results of this study require us to reevaluate the indications for TAVR in frail adults and recognize that improvement in disease-specific outcomes is not equivalent to improvement in outcomes that matter to older adults,” Carolyn D. Seib, MD, and Emily Finlayson, MD, MS, wrote in a related editorial. “Qualitative research has shown that the priorities of patients with severe aortic stenosis considering treatment options are focused on the ability to continue activities they enjoy and maintain independence (both of which rely on functional activity) and less commonly include resolution of symptoms and prolongation of life in comparison.”

The editorialists, both from the University of California, San Francisco, said physicians need to be careful going forward in their selection of the right patients for TAVR. As the intervention grows in popularity and specialized TAVR centers become more experienced, they said it’s “inevitable that they will push the boundaries of who should be offered the procedure.”

But Kim and colleagues’ study made it clear that frail patients don’t see the same positive outcomes from TAVR as their stronger counterparts, and research has found that cognitive and functional outcomes affect end-of-life patients’ treatment preferences more than mortality.

“As a part of shared decision-making, these goals should be weighed against a realistic assessment of whether they will be achieved with TAVR or SAVR according to a patient’s preoperative frailty and functional status,” Seib and Finlayson wrote. “If anticipated outcomes are not acceptable, alternative strategies to address symptom management would benefit this vulnerable patient population.”