Mortality and Other Adverse Events After TAVI Higher in Frailer Patients

Frailty assessed with a comorbidity-based risk-stratification tool correlates with long-term risks of mortality and geriatric symptoms following TAVI, according to new data.

Compared with patients classified as robust, those defined as frail using the 5-factor Modified Frailty Index (MFI-5) had significantly higher 5-year risks of mortality (HR 1.41; 95% CI 1.14-1.74), stroke (HR 18.52; 95% CI 8.13-42.19), ACS (HR 8.77; 95% CI 4.74-16.23), and major bleeding (HR 19.23; 95% CI 8.47-43.48).

“These findings support previous work showing that frailty enhances the prognostic performance of conventional risk scores,” write Osamah Badwan, MD (Cleveland Clinic, OH), and colleagues in their paper published online this week in JACC: Advances.

“Assessing biological aging throughout the lifespan is particularly important for younger patients undergoing TAVR,” they conclude. “The modified frailty index independently predicts long-term mortality and adverse events, including geriatric syndromes, in this population. Given its ease of use, reproducibility, and prognostic utility, the MFI provides a pragmatic tool which could aid in preprocedural assessment, optimize patient selection, and support shared decision-making.”

The MFI-5 factors in the following: a history of diabetes mellitus, hypertension, chronic obstructive pulmonary disease, congestive heart failure, and nonindependent functional status. Patients are then deemed robust (MFI-0), prefrail (MFI-2), or frail (MFI-5).

Commenting for TCTMD, Philippe Pibarot, DMV, PhD (Université Laval, Canada), said the MFI-5 measures more than just frailty, but that makes it a “good tool for risk stratification.” Also, the fact that it’s simple works in its favor. “It’s very fast and easy to calculate, and so I think it’s going to be widely adopted based on this new evidence.”

Comparing Frail Patients

For the study, researchers conducted three propensity score-matched analyses comparing robust with prefrail patients (n = 1,592 each; mean age at index 76.4 vs 77.0 years), robust with frail patients (n = 836 each; mean age 76.2 vs 76.4 years), and prefrail with frail patients (n = 1,233 each; mean age 76.5 vs 76.5 years). All data were taken from the global TriNetX Research Network for procedures performed between 2015 and 2023.

Compared with the robust group, both the prefrail and frail patients had higher rates of chronic kidney disease, heart failure, and atherosclerotic heart disease.

Overall outcomes worsened as frailty increased. Mortality at 5 years was higher in prefrail versus robust patients (20.1% vs 7.5%), in frail versus robust patients (27.6% vs 8.3%), and in frail versus prefrail patients (34% vs 19.6%).

The authors say they observed a “stepwise gradient in adverse outcomes with increasing frailty” across the board.

Additionally, geriatric syndromes like delirium (25.5%), incontinence (26.4%), depression (39.2%), and malnutrition (18.2%) were also more prevalent in frail patients compared with both robust and prefrail patients.

In an age-stratified analysis, the MFI-5 remained prognostically relevant across all age strata, including those under 65 years.

“As the TAVR population continues to include younger and lower-risk patients, it becomes even more important to assess frailty in a way that reflects biological aging, not just chronological age,” Badwan and colleagues write.

Pibarot agreed. Both the European and American guidelines for the treatment of aortic stenosis use age cutoffs for determining whether to go with TAVI or SAVR. “If there is evidence of frailty, then you should reconsider your choice and your discussion with the heart team,” he said. “If you don’t assess frailty, you will not reclassify patients toward the optimal therapy for them.”

The concept of assessing biological age will not be limited in its applicability to only aortic stenosis, but it’s a good place to start testing it, according to Pibarot.

The current study doesn’t address whether there are frailty thresholds at which, say, TAVI should be considered over SAVR or even when no procedures should be offered at all, but future studies should address this important question, he said.

“When patients are prefrail or robust, I think it’s okay to consider a SAVR. When they are frail, I think to me it’s a strong argument for going with a less invasive procedure like TAVR,” Pibarot said. “But there is probably another threshold that is higher where we should probably adopt a conservative management and not perform either SAVR or TAVR.”