Transcatheter Aortic Valve Replacement Outcomes in Nonagenarians Stratified by Transfemoral and Transapical Approach

• Published in: The Annals of thoracic surgery Vol. 103; no. 6; pp. 1808 - 1814
• Main Authors: McNeely, Christian, MD, Zajarias, Alan, MD, Robbs, Randall, MBA, Markwell, Stephen, MA, Vassileva, Christina M., MD
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01.06.2017
• Subjects: Age Factors; Aged; Aged, 80 and over; Aortic Valve Stenosis - surgery; Cardiothoracic Surgery; Cohort Studies; Databases, Factual; Female; Heart Valve Prosthesis; Humans; Male; Medicare; Prognosis; Surgery; Survival Analysis; Transcatheter Aortic Valve Replacement - adverse effects; Transcatheter Aortic Valve Replacement - methods; Transcatheter Aortic Valve Replacement - mortality; United States; PARTNER; FDA; OR; CI; CMS; odds ratio; Placement of Aortic Transcatheter Valves; TA; transapical; TAVR; LOS; ICD-9; TF; Centers for Medicare and Medicaid Services; International Classification of Diseases, Ninth Revision; TVT; transcatheter valve therapy; transfemoral; length of stay; transcatheter aortic valve replacement; confidence interval; CABG; Food and Drug Administration; coronary artery bypass grafting
• ISSN: 0003-4975; 1552-6259
• DOI: 10.1016/j.athoracsur.2017.02.056

Background Survival and other outcomes of nonagenarians undergoing transcatheter aortic valve replacement (TAVR) in the Medicare population are unclear. Methods Patients aged 65 years and older who underwent TAVR from November 2011 through 2013 were considered for inclusion. Results The study consisted of 18,283 patients and 19.3% were aged 90 years or older. Compared with patients younger than 90 years, patients 90 years or older were less likely to have a number of comorbidities, including previous myocardial infarction (17.5% versus 21.8%), previous coronary artery bypass grafting (20.0% versus 35.0%), and chronic obstructive pulmonary disease (25.4% versus 39.0%) among others. The 30-day and 1-year mortality rates were 8.4% versus 5.9% ( p  = 0.0001) and 25.4% versus 21.5% ( p  = 0.0001) in the older and younger groups, respectively (odds ratio [OR] 1.47, 95% confidence interval [CI]: 1.28 to 1.70, p  = 0.0001). Patients 90 years and older were more likely to undergo pacemaker insertion (11.1% versus 8.3%, p  = 0.0001). Among nonagenarians, compared with the transapical group, patients undergoing transfemoral TAVR had lower 30-day (7.2% versus 13.6%, p  = 0.0001) and 1-year (23.8% versus 31.6%, p  = 0.0001) mortality rates, were more likely to be discharged home (54.4% versus 34.1%, p  = 0.0001), and had lower 30-day readmission rates (23.8% versus 31.8%, p  = 0.0001). After adjustment for patient characteristics, transapical TAVR was an independent predictor of 30-day mortality rate (OR 1.94, 95% CI: 1.48 to 2.56, p  = 0.0001) and readmission (OR 1.46, 95% CI: 1.19 to 1.80, p  = 0.0003). Conclusions In patients undergoing TAVR, although 30-day and 1-year mortality rates were slightly worse for nonagenarians than their younger counterparts, long-term survival was still encouraging, with 75% of nonagenarians living to 1 year. Transapical TAVR was associated with worse outcomes in nonagenarians.