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Selection Criteria For Tavi In Octogenarians: Time To Change?

Paolo M. Tartara, Davide Patrini, Emanuela Tavasci, Nicola G. Valerio, Elena Perlasca, Piersilvio Gerometta, Pasquale Pellegrino, Vincenzo Arena, Ettore Vitali.
Cliniche Humanitas Gavazzeni, Bergamo, Italy.


OBJECTIVE:
Transcatheter aortic valve implantation (TAVI) should currently be restricted to patients at high-risk or with contraindications for surgery. The most widely used selection criteria for TAVI are based on a logistic Euroscore >20%. Is this cutoff-value in octogenarians still valid, or less strict criteria may be adopted?
METHODS:
In the last three years 100 octogenarians with severe aortic stenosis were screened for aortic valve replacement (AVR). Standard AVR (group A) was performed on 64 patients, in 33 cases with concomitant CABG. Inoperable and high risk patients (group B, n = 28) underwent TAVI (25 transapical, 3 transfemoral), in 11 cases preceded by PTCA. 2 patients operated on (AVR) in emergency and other 6 patients addressed to medical therapy were not considered. Logistic Euroscore (logES) >20% was used systematically to select high risk patients. Patients in group B were significantly older (81.7 vs 84.5 years), at higher risk for surgery (mean logES 10.7%, in group A and 33.4% in group B), and in worse NYHA functional class
RESULTS:
30 day mortality and morbidity were similar: mortality 7.8% vs 3.6% (p=ns), acute renal failure 16.1% vs 17.8% (p=ns), stroke 6.2% vs 3.6% (p=ns), PM implantation 3.6% vs 0% (p=ns) in groups A and B, respectively. Mean mechanical ventilation (40.5 vs 28.8 hours in group A and B) and ICU stay (81.3 vs 56.5 hours in group A and B) were shorter in group B, with no statistical significance. Postoperative atrial fibrillation and transfusions requirement were lower in group B. Significant liver disease and/or cachexia were present in the 5 patients died in group A. Patients in group B showed lower mean prosthetic gradient (8.4 mmHg vs 16.1 mmHg, p<0.001), but mild (≤2+/4+) aortic regurgitation in 18/28 cases.
CONCLUSIONS:
TAVI in octogenarians is a safe and reliable procedure: compared to standard AVR, it can afford similar clinical results, but in a higher risk patients population, and with less invasiveness. This may suggest, in octogenarians, a possible extension of current selection criteria for TAVI. In addition to Euroscore, risk assessment should be performed taking into account factors like liver disease and frailty.
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