Affecting an estimated one in eight people older than 75, aortic valve stenosis - a narrowing of the heart's main artery - makes the heart work harder to supply the body with blood, potentially limiting patient's activity levels an quality of life. Ultimately, aortic stenosis can lead to stroke, arrhythmia, heart failure and death.
Expecting to improve longevity as well as restore quality of life, patients with aortic stenosis increasingly opt for one of two procedures to repair the aorta; surgical aortic valve replacement (SAVR), which requires opening up the chest cavity, or transcatheter aortic valve replacement (TAVR), an increasingly popular minimally-invasive procedure. However, while valve repair has been shown to increase longevity, many patients' quality of life continues to decline.
In a paper published today in the Journal of the American Medical Association Internal Medicine, leading gerontologists at Beth Israel Deaconess Medical Center (BIDMC) assessed the change in patients' functional status during the year following valve replacement procedure. The team, led by Dae Hyun Kim, MD, demonstrated that patient outcomes were tightly linked to patients' pre-operative health status, and were also associated with post-operative complications and delirium.
"Quality of life can be more meaningful than longevity to older adults," said Kim, an assistant professor of medicine in BIDMC's Division of Gerontology. "Although procedural outcomes for TAVR and SAVR have improved over time, functional decline following the procedure is common. Information about the likelihood of seeing improvement after the procedure is essential for patient-centered decision-making and perioperative care to improve functional recovery."
To glean that information, Kim and colleagues conducted comprehensive geriatric assessments for 246 patients older than 70 prior to undergoing TAVR or SAVR procedures. Next, the researchers calculated participants' functional status using a standard frailty index commonly used in geriatrics. After patients underwent valve repair procedures, researchers conducted telephone interviews to assess patients' self-reported ability to perform a range of daily mental and physical tasks - such as walking up a flight of stairs, handling small objects and managing money - one, three, six, nine and 12 months after the procedure.
The team found that patients with high functional status and lower scores on the frailty index prior to valve replacement fared best after it. After SAVR - an open-heart procedure reserved for those well enough to tolerate the surgery - three quarters of patients experience functional improvement, with 19 percent remaining stable and just four percent experiencing a decline. Among those who underwent the minimally-invasive TAVR - by definition a frailer group - only 37 percent of patients' functional status improved. About the same amount of patients, 38 percent, saw no improvement, while nearly a quarter of patients continued to decline.
Patients' frailty index scores prior to undergoing valve replacement procedures helped predict patients' chances of improvement, stability or decline. Post-operative delirium and major complications were also linked to declines in functional status following the procedures.
The scientists note these data do not compare the effectiveness of SAVR versus TAVR, but can inform physician and patient decision making.
"These most likely, best-case and worst case scenarios can be communicated to the patient," said senior investigator Lewis A. Lipsitz, professor of medicine in the Division of Gerontology at who is also director of the Marcus Institute for Aging Research at Hebrew SeniorLife. "For patients who are frail, we can consider certain interventions to optimize health prior to valve repair."
The FRAILTY-AVR Functional Outcomes Study was conducted with the support of a KL2/Catalyst Medical Research Investigator Training award (an appointed KL2 award) and an additional support from Harvard Catalyst / The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award KL2 TR001100-01 and UL1 TR001102), National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health. Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School and consistently ranks as a national leader among independent hospitals in National Institutes of Health funding.
BIDMC is in the community with Beth Israel Deaconess Hospital-Milton, Beth Israel Deaconess Hospital-Needham, Beth Israel Deaconess Hospital-Plymouth, Anna Jaques Hospital, Cambridge Health Alliance, Lawrence General Hospital, Signature Healthcare, Beth Israel Deaconess HealthCare, Community Care Alliance and Atrius Health. BIDMC is also clinically affiliated with the Joslin Diabetes Center and Hebrew Rehabilitation Center and is a research partner of Dana-Farber/Harvard Cancer Center and the Jackson Laboratory. BIDMC is the official hospital of the Boston Red Sox. For more information, visit http://www.bidmc.org.
JAMA Internal Medicine