Comorbidities may offset expected improved survival after transcatheter aortic valve replacement

Pierre Lantelme; Matthieu Aubry; Jacques Chan Peng; Benjamin Riche; Géraud Souteyrand; Philippe Jaafar; Muriel Rabilloud; Brahim Harbaoui; Olivier Muller; Benoit Cosset; Mattia Pagnoni; Thibaut Manigold

doi:10.1093/ehjopen/oeac029

Comorbidities may offset expected improved survival after transcatheter aortic valve replacement

Eur Heart J Open. 2022 Apr 16;2(3):oeac029. doi: 10.1093/ehjopen/oeac029. eCollection 2022 May.

Affiliations

¹ Service de Cardiologie, Hôpital de la Croix-Rousse et Hôpital Lyon Sud, Hospices Civils de Lyon, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France.
² Département de cardiologie, Centre Hospitalo-Universitaire de Nantes, Nantes, France.
³ Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Université Lyon 1, Villeurbanne, France.
⁴ Département de cardiologie, Centre Hospitalo-Universitaire Gabriel Montpied, Image Science for Interventional Techniques, Cardiovascular Interventional Therapy and Imaging, Centre National de la Recherche Scientifique UMR 6284, Université d'Auvergne, Clermont-Ferrand, France.
⁵ Département de cardiologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
⁶ Department of Cardiac Surgery, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France.

Abstract

Aims: After transcatheter aortic valve replacement (TAVR), cardiovascular and non-cardiovascular comorbidities may offset the survival benefit from the procedure. We aimed to describe the relationships between that benefit and patient comorbidities.

Methods and results: The study pooled two European cohorts of patients with severe aortic stenosis (AS-pooled): one with patients who underwent (cohort of AS patients treated by TAVR, N = 233) and another with patients who did not undergo TAVR (cohort of AS patients treated medically; N = 291). The investigators collected the following: calcification prognostic impact (CAPRI) and Charlson scores for cardiovascular and non-cardiovascular comorbidities, activities of daily living (ADL)/instrumental activities of daily living (IADL) scores for frailty as well as routine Society of Thoracic Surgeons (STS) score and Logistic Euroscore. Unlike ADL/IADL scores, CAPRI and Charlson scores were found to be independent predictors of 1-year all-cause death in the AS-pooled cohort, with and without adjustment for STS score or Logistic Euroscore; they were thus retained to define a three-level prognostic scale (good, intermediate, and poor). The survival benefit from TAVR-vs. no TAVR-was stratified according to these three prognosis categories. The beneficial effect of TAVR on 1-year all-cause death was significant in patients with good and intermediate prognosis, hazard ratio (95% confidence interval): 0.36 (0.18; 0.72) and 0.32 (0.15; 0.67). That effect was reduced and not statistically significant in patient with poor prognosis [0.65 (0.22; 1.88)].

Conclusion: The study showed that, beyond a given comorbidity burden (as assessed by CAPRI and Charlson scores), the probability of death within a year was high and poorly reduced by TAVR. This indicates the futility of TAVR in patients in the poor prognosis category.

Keywords: Comorbidities; Medical futility; Mortality; Organ dysfunction scores; Transcatheter aortic valve replacement.