Transcatheter Aortic Valve Implantation in Nonagenarians

Objectives: Symptomatic medical treatment does little to improve the condition of elderly patients with severe aortic valve stenosis. Once the symptoms of congestive heart failure develop, the quality of life deteriorates substantially. In the past, these individuals were not offered valve replacement because of unacceptably high perioperative mortality and morbidity. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to conventional aortic valve replacement for management of aortic stenosis. In this report, we assess the outcome of TAVI in nonagenarians at our institution during a 5-year period.

Methods: In 04/2008–08/2014 40 patients aged 91.8 ± 2.3 (range 90–98) years underwent TAVI at our institution. Thirty-one (77.5%) received transapical TAVI and 9 (22.5%) transfemoral TAVI. Baseline characteristics were as follows: mean log. EuroSCORE 51.5 ± 18.6 (range 22.7–91.0), mean EuroSCORE II 23.9 ± 14.21 (range 5.5–66.4), mean STS mortality score 24.2 ± 11.4 (range 7.5–58.8), mean SYNTAX score 7.6 ± 9.3 (range 0–33), NYHA class 3.5 ± 0.5 (range 3.0–4.0), mean transvalvular gradient 46.8 ± 17.8 mmHg, mean aortic valve area 0.7 ± 0.2(range 0.4–1.0) sqcm. 70% of patients had coronary artery disease, 70% peripheral arterial disease.

Results: Peri- and postoperative complications were assessed according to VARC-2 criteria.

Operative mortality rate was 2.5% and 30-day all-cause mortality rate was 10%. The actuarial survival at 1 and 4 years was 59.1% and 30.7%, respectively.

Seven (17.5%) patients underwent simultaneous elective TAVI and PCI. Two (5%) were operated on with elective use of cardiopulmonary bypass (CPB), 1 (2.5%) patient needed emergency installation of CPB. One (2.5%) patient underwent intraoperative implantation of an additional valve prosthesis. No conversion to open surgery occurred.

In TEE assessment, no moderate or severe prosthetic aortic valve regurgitation was observed. Four (10%) patients had postoperative acute kidney failure stage 3 and needed new dialysis (p = 0.125). Peri-procedural myocardial infarction occurred in 1 (2.5%) patient. Three (7.5%) patients had a disabling stroke 90 days after TAVI.

Seven (17.5%) patients needed postoperative pacemaker implantation. No reoperation for aortic valve prosthesis replacement was necessary in the 5 years.

Conclusions: TAVI can be performed in nonagenarians, despite very high preoperative risk scores and patients' multimorbidity, with increased but acceptable mortality and manageable complications.