As transcatheter aortic valve replacement (TAVR) continues to gain momentum as a go-to treatment option for severe aortic stenosis (AS), it remains important to track its impact on different patient populations. The authors of a new study in the American Journal of Cardiology, for example, focused on TAVR among octogenarians (ages 80 to 89 years) and nonagenarians (ages 90 and up).
“Nonagenarians with severe AS are a challenging cohort of patients because they are often frail and have significant comorbid medical conditions,” wrote first author Mahmoud Ismayl, MD, a specialist with the department of internal medicine at Creighton University School of Medicine in Nebraska, and colleagues. “Surgical aortic valve replacement (SAVR) in this cohort of patients is often deferred because of high operative risk, and TAVR is the preferred treatment modality. However, nonagenarians were underrepresented in the clinical trials that evaluated the safety of TAVR … data on the outcomes of TAVR in nonagenarians and octogenarians are limited to small observational studies.”
Ismayl et al. examined National Inpatient Sample data from more than 260,000 TAVR patients treated from 2016 to 2022. The minimum patient age for inclusion in this study was 70 years old. While 12% of patients were nonagenarians at the time of treatment, 51.1% were octogenarians and all other patients were septuagenarians (ages 70 to 79).
An adjusted comparison between patient groups found that both octogenarians and nonagenarians had higher rates of in-hospital mortality than younger TAVR patients. Heart block, permanent pacemaker implantation, stroke, major bleeding events, blood transfusions and palliative care consultations were all also more common among these older patient groups.
Using both the Charlson comorbidity index and the Elixhauser comorbidity score, however, researchers found that seuptuagenarian TAVR patients presented with more comorbid conditions than nonagenarians or octogenarians.
“This was driven mainly by the lower rates of diabetes mellitus, hypertension, dyslipidemia, nicotine/tobacco use, alcohol and drug abuse, obesity, peripheral vascular disease, liver disease, chronic pulmonary disease, obstructive sleep apnea, cancer and depression in nonagenarians and octogenarians,” the authors wrote. “In contrast, nonagenarians and octogenarians were more likely to have atrial fibrillation/flutter, congestive heart failure, renal failure, malnutrition, and dementia.”
In addition, when just looking at outcomes among just nonagenarians, the group found that female patients and patients with an ongoing history of cancer or liver disease faced a significantly higher risk of in-hospital mortality.
As one might expect, elderly TAVR patients were also linked to higher hospital costs and longer lengths of stay. The median total hospital costs for nonagenarians, octogenarians and septuagenarians were $55,884, $54,482 and $51,617, respectively. The median length of stay was three days for the two older patient groups and two days for septuagenarians.
Many TAVR outcomes for elderly patients are improving over time
From 2016 to 2020, researchers noted, TAVR utilization “increased significantly” among all patient groups. In-hospital mortality dropped significantly among nonagenarians and stayed the same for the other two groups. The risk of many other outcomes—permanent pacemaker implantation and major bleeding events, for example—dropped for all TAVR patients, regardless of age.
“Improvements in in-hospital mortality and most procedural complications after TAVR likely represent advances in procedural technique, technological advancements, and improved patient selection for TAVR, even in the era of an expanded patient pool eligible for TAVR,” the authors wrote, noting that length of stay and hospital costs are also trending down as time goes on.
Stroke is the one TAVR complication that does not seem to be improving as time goes on. It remains a risk for nonagenarians, octogenarians and septuagenarians.
“This may be because of similar risks of embolizing calcified valve material during TAVR deployment inside a calcified aortic valve; this stroke risk is inherent to the deployment of the valve during the TAVR procedure, regardless of sheath size or operator skill,” the group wrote.
Co-authors for this analysis included researchers from Mayo Clinic, Baystate Medical Center and the University of Nebraska Medical Center.
Read the full study here.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.