Clinician-to-Clinician Update Clinician-to-Clinician Update

Successful TAVR Despite Advanced Age, Co-Morbidity, and Impaired Functional Ability

February 2015

An elderly patient with severe, symptomatic aortic stenosis (AS), co-morbid conditions, and impaired functional ability can be a candidate for transcatheter aortic valve replacement (TAVR) after careful evaluation. Here we describe a female patient who was not a candidate for traditional open-chest surgery due to advanced age, poor functional class, and frailty. She successfully underwent a TAVR procedure at a University of Minnesota Heart Care location, resulting in a positive long-term outcome.

Patient

An 87-year-old female patient was referred to University of Minnesota Heart Care physicians for an evaluation of shortness of breath and fatigue. She had a history of hypertension, hyperlipidemia, and severe aortic valve stenosis. Although the patient had been fairly active for her age, managing her own life coaching business, she had recently become quite limited in her activity level because of worsening shortness of breath and fatigue. She was not considered a candidate for open-chest surgery.

Aortic-valve-TAVR-procedure-443x301
— Self-expanding replacement aortic valve placed during TAVR procedure.

Management

The patient underwent a comprehensive evaluation by our multidisciplinary TAVR team. Because she had acceptable kidney function, cognitive status, and no other conditions that would limit lifespan, it was decided that a TAVR procedure using a transfemoral approach was indicated. The patient’s valve gradient before the procedure was 35 mm Hg, and the valve area was 0.8 cm 2.

The patient received a 26-mm self-expanding valve (Figure 1), and she recovered without any complications. After TAVR, the valve gradient was 6 mm Hg, and the valve area was 2.0 cm 2. The patient was discharged home on the third day after the procedure. Currently, she feels well at 7-months postsurgery, is participating in cardiac rehabilitation, and has returned to work. The patient notices only occasional shortness of breath with exertion, but never at rest. She denies any chest pain or pressure and has not had palpitations, presyncope, or syncope.

Discussion

Even in an elderly patient with co-morbid conditions, outcomes are often very good after TAVR. For example, in the pivotal phase III PARTNER trial, 358 patients with severe AS who were not considered suitable candidates for openchest surgery were randomized to TAVR or standard care. 1

The mean age of the patient population in this trial was about 83 years, and the mean Society of Thoracic Surgeons score at baseline was 11.6 ±6%, a prohibitive surgical risk level. At one year postsurgery, the rate of death from any cause was 50.7% with standard therapy but was reduced to 30.7% with TAVR. In postmarketing studies, this rate has further improved to 19%. 2

While not suitable for all patients with severe AS and high-to-prohibitive surgical risk, careful patient selection and choice of approach can provide many patients with increased lifespan and improved quality of life.

References

1. Leon MB, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597-1607.

2. Fearon WF, et al. Outcomes after transfemoral transcatheter aortic valve replacement: a comparison of the randomized PARTNER (Placement of AoRTic TraNscathetER Valves) trial with the NRCA (Nonrandomized Continued Access) Registry. JACC Cardiovasc Interv. 2014;7:1245-1251

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