TAVR in older adults with cardiogenic shock: current practice and future direction

Abstract

Aortic stenosis (AS) is one of the most common types of valvular heart disease in older adults, with age being significantly associated with the development of AS. The transcatheter aortic valve replacement (TAVR) procedure, since it was first performed in 2002, has emerged as a preferred treatment option for patients who are at intermediate to high surgical risk due to advanced age or medical comorbidities. Older adults with severe AS may present with acute decompensated heart failure leading to cardiogenic shock (CS). Among patients 65 years and older with AS presenting for TAVR, 4.1% were reportedly in acute CS. Regardless of etiology, mortality from CS itself is high (30%-50%) and increases with advancing age. TAVR for these patients could provide a definite treatment for both AS and CS. There is still limited evidence regarding the safety and efficacy of TAVR in this population, but recent studies are promising, with successful procedural results and a good recovery rate after the procedure. However, particularly for older adults, there are other factors that clinicians should consider during pre- and post-procedural status, such as patient's goals, frailty, polypharmacy, dementia, or delirium. In this article, we reviewed current studies regarding TAVR for older adults with AS and CS, the reason for comprehensive geriatric assessment, and the introduction of appropriate geriatric assessment tools based on the Age-Friendly 4Ms framework that cardiologists can adopt in real-world practice.

Figure 1

Special consideration for older adults with AS and CS in the management of TAVR. AS: aortic stenosis; CS: cardiogenic shock; TAVR: transcatheter aortic valve replacement.