Original Investigation
Frailty in Older Adults Undergoing Aortic Valve Replacement: The FRAILTY-AVR Study

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Abstract

Background

Frailty is a geriatric syndrome that diminishes the potential for functional recovery after a transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) procedure; however, its integration in clinical practice has been limited by a lack of consensus on how to measure it.

Objectives

This study sought to compare the incremental predictive value of 7 different frailty scales to predict poor outcomes following TAVR or SAVR.

Methods

A prospective cohort of older adults undergoing TAVR or SAVR was assembled at 14 centers in 3 countries from 2012 to 2016. The following frailty scales were compared: Fried, Fried+, Rockwood, Short Physical Performance Battery, Bern, Columbia, and the Essential Frailty Toolset (EFT). Outcomes of interest were all-cause mortality and disability 1 year after the procedure.

Results

The cohort was composed of 1,020 patients with a median age of 82 years. Depending on the scale used, the prevalence of frailty ranged from 26% to 68%. Frailty as measured by the EFT was the strongest predictor of death at 1 year (adjusted odds ratio [OR]: 3.72; 95% confidence interval [CI]: 2.54 to 5.45) with a C-statistic improvement of 0.071 (p < 0.001) and integrated discrimination improvement of 0.067 (p < 0.001). Moreover, the EFT was the strongest predictor of worsening disability at 1 year (adjusted OR: 2.13; 95% CI: 1.57 to 2.87) and death at 30 days (adjusted OR: 3.29; 95% CI: 1.73 to 6.26).

Conclusions

Frailty is a risk factor for death and disability following TAVR and SAVR. A brief 4-item scale encompassing lower-extremity weakness, cognitive impairment, anemia, and hypoalbuminemia outperformed other frailty scales and is recommended for use in this setting. (Frailty Assessment Before Cardiac Surgery & Transcatheter Interventions; NCT01845207)

Key Words

aortic stenosis
disability
frailty
outcomes
surgical aortic valve replacement
survival
transcatheter aortic valve replacement

Abbreviations and Acronyms

ADL
activities of daily living
BIC
Bayesian information criterion
CFS
Clinical Frailty Scale
EFT
Essential Frailty Toolset
IADL
instrumental activities of daily living
IDI
integrated discrimination improvement
SAVR
surgical aortic valve replacement
SPPB
Short Physical Performance Battery
STS-PROM
Society of Thoracic Surgeons Predicted Risk of Mortality
TAVR
transcatheter aortic valve replacement

Cited by (0)

The FRAILTY-AVR Study was funded by an Operating Grant from the Canadian Institutes for Health Research, a Clinical Research Scholars Award from the Fonds de Recherche du Québec en Santé, and a Research Fellowship Award from the Heart and Stroke Foundation of Canada. Dr. Lauck has served as a consultant to Edwards Lifesciences. Dr. D. Kim has served as a consultant to Alosa Health (nonprofit). Dr. Lefèvre has been a proctor for Edwards Lifesciences. Dr. Piazza has served as a consultant to Highlife, Microport, Boston Scientific, and Medtronic. Dr. Martucci has served as a consultant to Boston Scientific; and has been a proctor for Boston Scientific and Medtronic. Dr. Peterson has been a proctor for Edwards Lifesciences; and has served as a consultant for Edwards Lifesciences and LivaNova. Dr. Arora has received an unrestricted educational grant from Pfizer; has received honoraria from Mallickrodt Pharmaceutical; and has served on the advisory board for CSU-ALS North America. Dr. Palacios has served on the advisory boards of Medtronic, Abbott Vascular, Siemens, Abiomed, St. Jude Medical, and Ample Medical; and has been a proctor for St. Jude Medical and Edwards Lifesciences. Dr. Généreux has been a proctor for Edwards Lifesciences and Medtronic; and has received speaker fees from Medtronic. Dr. Lindman has served on the advisory board of Roche Diagnostics; has served as a consultant to Medtronic, Edwards Lifesciences, and Roche Diagnostics; and has received grant support from Roche Diagnostics and Edwards Lifesciences. Dr. Asgar has served as a consultant to Edwards Lifesciences and Medtronic. Dr. Morais has served on the advisory boards of Pfizer and Astellas. Dr. Rudski has minor stock holding outside of a managed portfolio in General Electric. Dr. Popma has received institutional grants from Medtronic and Abbott Vascular; and has served on the advisory boards of Boston Scientific and Abbott Vascular. Dr. Webb has served as a consultant to Edwards Lifesciences and Abbott Vascular. Dr. Perrault has served as a consultant to Somahlution; and has served on the advisory board of Clearflow. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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