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Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention

Published on Jun 1, 2014in Journal of Internal Medicine6.051
· DOI :10.1111/joim.12174
Manuel Martínez-Sellés21
Estimated H-index: 21
(Hospital General Universitario Gregorio Marañón),
J. J. Gómez Doblas1
Estimated H-index: 1
+ 12 AuthorsRamón López-Palop23
Estimated H-index: 23
Abstract
Objective To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). Study Design Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. Setting Transnational registry in Spain. Subjects We included 928 patients aged ≥80 years with severe symptomatic AS. Interventions Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. Main outcome measures All-cause death. Results Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2–38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49–0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39–0.8; P = 0.002). Conclusion Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.
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  • Citations (28)
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References47
Newest
#1Andreas W. Schoenenberger (University of Bern)H-Index: 19
#2N WernerH-Index: 1
Last. Andrea Ungar (UniFI: University of Florence)H-Index: 31
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Abstract Purpose Aortic stenosis (AS) is the most common valvular abnormality in the elderly population. For inoperable patients or those at high-risk for surgery, transcatheter aortic valve implantation (TAVI) has become an alternative therapeutic option. The aim of the “Comprehensive geriatric assessment for transcatheter aortic valve implantation” (CGA-TAVI) registry is to evaluate the effectiveness of TAVI from the perspective of the geriatrician and to identify patient characteristics and i...
11 CitationsSource
#1Andrea Ungar (UniFI: University of Florence)H-Index: 31
#2Peter BramlageH-Index: 36
Last. J.-P. MichelH-Index: 1
view all 5 authors...
Abstract Aortic stenosis (AS) represents a significant healthcare burden in the elderly population. For inoperable patients or those at high-risk for surgery, transcatheter aortic valve implantation (TAVI) has become an alternative therapeutic option. The recently conducted European Union Geriatric Medicine Society (EUGMS) TAVI survey found that the involvement of geriatricians in the management of patients undergoing TAVI is generally low. Because of the complexity and rapidly progressive natur...
10 CitationsSource
#1Andreas W. Schoenenberger (University of Bern)H-Index: 19
#2Stefan Stortecky (University of Bern)H-Index: 33
Last. Peter Wenaweser (University of Bern)H-Index: 53
view all 13 authors...
Aims This study aimed to assess functional course in elderly patients undergoing transcatheter aortic valve implantation (TAVI) and to find predictors of functional decline. Methods and results In this prospective cohort, functional course was assessed in patients ≥70 years using basic activities of daily living (BADL) before and 6 months after TAVI. Baseline EuroSCORE, STS score, and a frailty index (based on assessment of cognition, mobility, nutrition, instrumental and basic activities of dai...
171 CitationsSource
#3Alec Vahanian (University of Paris)H-Index: 93
#4Ottavio Alfieri Fects (UniSR: Vita-Salute San Raffaele University)H-Index: 71
Last. Thomas WaltherH-Index: 79
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ACE : angiotensin-converting enzyme AF : atrial fibrillation aPTT : activated partial thromboplastin time AR : aortic regurgitation ARB : angiotensin receptor blockers AS : aortic stenosis AVR : aortic valve replacement BNP : B-type natriuretic peptide BSA : body surface area CABG : coronary artery bypass grafting CAD : coronary artery disease CMR : cardiac magnetic resonance CPG : Committee for Practice Guidelines CRT : cardiac resynchronization therapy CT : computed tomography EACTS : European...
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#1Mary Ann ClarkH-Index: 7
#2Suzanne V. Arnold (UMKC: University of Missouri–Kansas City)H-Index: 15
Last. David J. Cohen (UMKC: University of Missouri–Kansas City)H-Index: 109
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Background—Patients with severe, symptomatic aortic stenosis, who do not undergo valve replacement surgery have a poor long-term prognosis. Limited data exist on the medical resource utilization and costs during the final stages of the disease. Methods and Results—We used data from the 2003 Medicare 5% standard analytic files to identify patients with aortic stenosis and a recent hospitalization for heart failure, who did not undergo valve replacement surgery within the ensuing 2 calendar quarte...
46 CitationsSource
#1Hans Van BrabandtH-Index: 12
#2Mattias NeytH-Index: 18
Last. Frank HulstaertH-Index: 24
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Many of the 40 000 transcatheter procedures so far carried out cannot be justified on medical or cost effectiveness grounds. Hans Van Brabandt , Mattias Neyt , and Frank Hulstaert examine why practice has gone beyond the evidence
60 CitationsSource
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#1Raj MakkarH-Index: 61
#2Gregory P. FontanaH-Index: 26
Last. Martin B. LeonH-Index: 151
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BackgroundTranscatheter aortic-valve replacement (TAVR) is the recommended therapy for patients with severe aortic stenosis who are not suitable candidates for surgery. The outcomes beyond 1 year in such patients are not known. MethodsWe randomly assigned patients to transfemoral TAVR or to standard therapy (which often included balloon aortic valvuloplasty). Data on 2-year outcomes were analyzed. ResultsA total of 358 patients underwent randomization at 21 centers. The rates of death at 2 years...
864 CitationsSource
#1Susheel Kodali (Columbia University)H-Index: 63
#2Mathew R. Williams (Columbia University)H-Index: 43
Last. Trial InvestigatorsH-Index: 3
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The rates of death from any cause were similar in the TAVR and surgery groups (hazard ratio with TAVR, 0.90; 95% confidence interval [CI], 0.71 to 1.15; P = 0.41) and at 2 years (Kaplan–Meier analysis) were 33.9% in the TAVR group and 35.0% in the surgery group (P = 0.78). The frequency of all strokes during follow-up did not differ significantly between the two groups (hazard ratio, 1.22; 95% CI, 0.67 to 2.23; P = 0.52). At 30 days, strokes were more frequent with TAVR than with surgical replac...
1,546 CitationsSource
#1Stefan Stortecky (University of Bern)H-Index: 33
#2Andreas W. Schoenenberger (University of Bern)H-Index: 19
Last. Peter Wenaweser (University of Bern)H-Index: 53
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Objectives This study evaluated Multidimensional Geriatric Assessment (MGA) as predictor of mortality and major adverse cardiovascular and cerebral events (MACCE) after transcatheter aortic valve implantation (TAVI). Background Currently used global risk scores do not reliably estimate mortality and MACCE in these 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...
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OBJECTIVE: The aim of our study was to evaluate the outcome of patients with severe aortic stenosis presenting with acute decompensated heart failure (ADHF) and planned for transcatheter aortic valve implantation (TAVI) and to study the variables influencing their prognosis. METHODS: Our retrospective study included 801 patients planned for TAVI in our center. Seven hundred and fifty-six underwent TAVI and were categorized according to ADHF as the initial clinical presentation into two groups: A...
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#1M. RamosH-Index: 1
#2Maribel QuezadaH-Index: 4
Last. Rocio ToroH-Index: 8
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Resumen Introduccion y objetivos El pronostico de la estenosis aortica (EAo) grave asintomatica en la poblacion anciana, que a menudo asocia fragilidad y comorbilidades no ha sido estudiado. Se propuso analizar que factores podrian influir en la mortalidad precoz esta poblacion. Metodos Estudio ambispectivo de cohortes en 104 pacientes con edad ≥ 70 anos y EAo grave asintomatica. Se recogieron variables epidemiologicas, geriatricas, clinicas y ecocardiograficas y se compararon entre pacientes fr...
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Resumen Las enfermedades cardiovasculares son muy frecuentes en la poblacion anciana (pacientes mayores de 75 anos). El enfrentamiento y manejo de ellas es distinto al indicado en pacientes jovenes. Son escasos los estudios que incluyen poblacion mayor de 75 anos, con evidencia acerca de las diferencias que existen en la respuesta terapeutica en comparacion al paciente joven. El anciano tiene mayor fragilidad y multiples comorbilidades, con reserva cardiaca disminuida, lo que obliga a un manejo ...
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Abstract Introduction and objectives The prognosis of asymptomatic severe aortic stenosis (AS) has not been widely documented in elderly patients who are frequently frail and have comorbidities. We sought to analyze the factors that influence early mortality in geriatric patients with asymptomatic severe AS. Methods This ambispective cohort study included 104 patients aged 70 years or older with asymptomatic severe AS. Epidemiological, geriatric, clinical and echocardiographic variables were col...
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#1Hugo González Saldivar (Hospital General Universitario Gregorio Marañón)H-Index: 1
#2Lourdes Vicent Alaminos (Hospital General Universitario Gregorio Marañón)H-Index: 1
Last. Manuel Martínez-SellésH-Index: 21
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Abstract Introduction and objectives Current therapeutic options for severe aortic stenosis (AS) include transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Our aim was to describe the prognosis of patients with severe AS after the decision to perform an intervention, to study the variables influencing their prognosis, and to describe the determinants of waiting time > 2 months. Methods Subanalysis of the IDEAS (Influence of the Severe Aortic Stenosis Dia...
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#1Hugo González Saldivar (Hospital General Universitario Gregorio Marañón)H-Index: 1
#2Lourdes Vicent Alaminos (Hospital General Universitario Gregorio Marañón)H-Index: 1
Last. Manuel Martínez-SellésH-Index: 21
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Resumen Introduccion y objetivos Los tratamientos actuales de la estenosis aortica (EAo) grave incluyen el implante percutaneo de valvula aortica (TAVI) y la cirugia de sustitucion valvular aortica (SVAo). El objetivo es describir la evolucion de los pacientes con EAo grave tras la indicacion de intervencion, las variables que influyen en su pronostico y los determinantes de un tiempo de espera superior a 2 meses. Metodos Subanalisis del registro IDEAS (Influencia del Diagnostico de Estenosis Ao...
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#1Kazuya NagaoH-Index: 16
#2Tomohiko Taniguchi (Kyoto University)H-Index: 9
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Prognostic impact of anemia complicating severe aortic stenosis (AS) remains unclear. We assessed the impact of anemia on cardiovascular and bleeding outcomes in 3403 patients enrolled in the CURRENT AS registry. 835 patients (25%) had mild (hemoglobin 11.0–12.9 g/dl for men/11.0–11.9 g/dl for women) and 1282 patients (38%) had moderate/severe anemia (Hb ≤ 10.9 g/dl) at diagnosis of severe AS. Mild and moderate/severe anemia were associated with significantly increased risks relative to no anemi...
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#1Juan José Gómez Doblas (UMA: University of Málaga)H-Index: 21
#2Miguel A. López-Garrido (UMA: University of Málaga)H-Index: 3
Last. Manuel Martínez-Sellés (Complutense University of Madrid)H-Index: 21
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Abstract Introduction The coexistence of significant mitral regurgitation (MR) and severe aortic stenosis is prevalent, has a prognostic impact and makes treatment in the elderly population a complex issue. The aim of this study is to determine the prevalence of significant MR among a population of octogenarians and its influence on treatment and prognosis. Methods We used the data from PEGASO (Pronostico de la Estenosis Grave Aortica Sintomatica del Octogenario), a prospective registry that con...
1 CitationsSource