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

Comorbidities may offset expected improved survival after transcatheter aortic valve replacement

Pierre Lantelme  1 , Matthieu Aubry  1 , Jacques Chan Peng  2 , Benjamin Riche  3 , Géraud Souteyrand  4 , Philippe Jaafar  2 , Muriel Rabilloud  3 , Brahim Harbaoui  1 , Olivier Muller  5 , Benoit Cosset  6 , Mattia Pagnoni  5 , Thibaut Manigold  2
Affiliations

Comorbidities may offset expected improved survival after transcatheter aortic valve replacement

Pierre Lantelme et al. Eur Heart J Open. .

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.

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Figures

Graphical Abstract
Graphical Abstract
Relationship between prognosis category and the transcatheter aortic valve replacement (TAVR) effect. Prognosis categories were defined using the tertiles of calcification prognostic impact and Charlson scores. The estimates of 1-year all-cause death probabilities in each cohort (cohort of AS patients treated medically and cohort of AS patients treated by TAVR) were obtained using a multivariable Cox regression model. The mortality curves were obtained using an interpolated polynomial of degree 2 based on those estimates. The hatched area indicates the difference in the probability of 1-year death between the two cohorts and illustrates mainly the TAVR effect. While both TAVR and the prognosis category contributed to 1-year all-cause death, the contribution of TAVR was not uniform across the range of prognoses; the poorer was the prognosis category, the lower was the benefit from TAVR.
Figure 1
Figure 1
Study flow chart.
Figure 2
Figure 2
Correlations between calcification prognostic impact score, Society of Thoracic Surgeons score, Logistic Euroscore, Charlson score, instrumental activities of daily living, and activities of daily living scores in the Aortic Stenosis pooled cohort. The size and colour of each circle represent the direction and the strength of the correlation.
Figure 3
Figure 3
Distribution of the three prognosis categories in the aortic stenosis cohort treated medically and the aortic stenosis cohort treated by transcatheter aortic valve replacement.
Figure 4
Figure 4
Probability of death in cohort of aortic stenosis patients treated by transcatheter aortic valve replacement vs. cohort of aortic stenosis patients treated medically in the good (upper panel), intermediate (middle panel), and poor (lower panel) prognosis categories.
None
See this image and copyright information in PMC

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