Evaluation of Changes in Functional Status in the Year After Aortic Valve Replacement | Valvular Heart Disease | JAMA Internal Medicine | JAMA Network
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    Original Investigation
    February 4, 2019

    Evaluation of Changes in Functional Status in the Year After Aortic Valve Replacement

    Author Affiliations
    • 1Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
    • 2Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
    • 3Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
    • 4Centre for Clinical Epidemiology, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
    • 5Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
    • 6Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
    • 7Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
    JAMA Intern Med. 2019;179(3):383-391. doi:10.1001/jamainternmed.2018.6738
    Key Points

    Question  How does functional status change in the year after transcatheter and surgical aortic valve replacement?

    Findings  In this cohort study of 246 elderly patients (mean age, 78.1 years), the proportions of patients who had excellent, good, fair, poor, and very poor functional trajectories were 14.0%, 23.1%, 37.9%, 14.7%, and 8.4%, respectively, after transcatheter aortic valve replacement, and 36.9%, 37.9%, 19.4%, 2.9%, and 1.0%, respectively, after surgical aortic valve replacement. Preoperative frailty level as well as major complications and delirium were associated with functional decline or lack of improvement.

    Meaning  Despite disease-specific benefits of aortic valve replacement, functional decline or lack of functional improvement is common in older patients with severe frailty; information on functional trajectories may be useful for patient-centered decision making and perioperative care to optimize functional outcomes.

    Abstract

    Importance  Functional status is a patient-centered outcome that is important for a meaningful gain in health-related quality of life after aortic valve replacement.

    Objective  To determine functional status trajectories in the year after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).

    Design, Setting, and Participants  A prospective cohort study with a 12-month follow-up was conducted at a single academic center in 246 patients undergoing TAVR or SAVR for severe aortic stenosis. The study was conducted between February 1, 2014, and June 30, 2017; data analysis was performed from December 27, 2017, to May 7, 2018.

    Exposures  Preoperative comprehensive geriatric assessment was performed and a deficit-accumulation frailty index (CGA-FI) (range, 0-1; higher values indicate greater frailty) was calculated.

    Main Outcomes and Measures  Telephone interviews were conducted to assess self-reported ability to perform 22 activities and physical tasks at 1, 3, 6, 9, and 12 months after the procedure.

    Results  Of the 246 patients included in the study, 143 underwent TAVR (74 [51.7%] women; mean [SD] age, 84.2 [5.9] years), and 103 underwent SAVR (46 [44.7%] women; age, 78.1 [5.3] years). Five trajectories were identified based on functional status at baseline and during the follow-up: from excellent at baseline to improvement at follow-up (excellent baseline-improvement), good (high baseline-full recovery), fair (moderate baseline-minimal decline), poor (low baseline-moderate decline), and very poor (low baseline-large decline). After TAVR, the most common trajectory was fair (54 [37.8%]), followed by good (33 [23.1%]), poor (21 [14.7%]), excellent (20 [14.0%]), and very poor (12 [8.4%]) trajectories. After SAVR, the most common trajectory was good (39 [37.9%]), followed by excellent (38 [36.9%]), fair (20 [19.4%]), poor (3 [2.9%]), and very poor (1 [1.0%]) trajectories. Preoperative frailty level was associated with lower probability of functional improvement and greater probability of functional decline. After TAVR, patients with CGA-FI level of 0.20 or lower had excellent (3 [50.0%]) or good (3 [50.0%]) trajectories, whereas most patients with CGA-FI level of 0.51 or higher had poor (10 [45.5%]) or very poor (5 [22.7%]) trajectories. After SAVR, most patients with CGA-FI level of 0.20 or lower had excellent (24 [58.5%]) or good (15 [36.6%]) trajectories compared with a fair trajectory (5 [71.4%]) in those with CGA-FI levels of 0.41 to 0.50. Postoperative delirium and major complications were associated with functional decline after TAVR (delirium present vs absent: 14 [50.0%] vs 11 [13.4%]; complications present vs absent: 14 [51.9%] vs 19 [16.4%]) or lack of improvement after SAVR (delirium present vs absent: 27 [69.2%] vs 31 [81.6%]; complications present vs absent: 10 [62.5%] vs 69 [79.3%]).

    Conclusions and Relevance  The findings suggest that functional decline or lack of improvement is common in older adults with severe frailty undergoing TAVR or SAVR. Although this nonrandomized study does not allow comparison of the effectiveness between TAVR and SAVR, anticipated functional trajectories may inform patient-centered decision making and perioperative care to optimize functional outcomes.

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