Jarosław Trębacz

Klinika Kardiologii InterwencyjnejInstytut Kardiologii

Collegium Medicum Uniwersytet Jagielloński

Symptomatic patients with AS require early intervention,because no medical therapy is able to improve outcome,compared with the natural history.

Operative mortality of isolated AVR for AS is 1-3% in patientsyounger than 70 years and 4-8% in selected older adults.After successful AVR symptoms and quality of life are in generalgreatly improved.In elderly patients long-term survival may be close to the age-matched general population.Surgery has been shown to prolong and improve quality of life,even in selected patients over 80 years of age. Age shouldtherefore not be considered a contraindication for surgery.A large percentage of suitable candidates are currently notreferred for surgery.

Surgery was denied in 33% of elderly patients with severe, symptomatic AS.

Older age and LV dysfunction were the most striking characteristics of patients who were denied surgery. Comorbidity played a less important role.

Balloon valvuloplasty plays a very limited role, when used in isolation, in adults.

Its efficacy is limited as restenosis and clinical deterioration occur within 6-12 months in most patients, resulting in mid-and long-term outcome similar to natural history.

Balloon valvuloplasty may be considered as a bridge tosurgery or TAVI in hemodynamically unstable patients whoare at high risk for surgery or in patients with symptomaticsevere AS who require major non-cardiac surgery.

It may be considered as a palliative measure in selectedindividual cases when surgery is contraindicated because ofsevere comorbidities and when TAVI is not an option.

Transcatheter Aortic Valve Implantation - TAVI

29 March 2014 ACC Scientific Session:

Among patients with severe aortic stenosis who are at increased surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding bioprosthesis is associated with better survival at 1 year compared with surgery.

The rate of all-cause death at 1 year was lower with TAVR compared with surgery in the as-treated analysis (14.2% vs 19.1%; P < 0.001 for noninferiority; P = 0.04 for superiority).

Logistic Euroscore ≥ 20% has been suggested as an indicator for TAVI but it markedly overestimates operative mortality.

Use of the STS scoring system ≥ 10% may result in a more realistic assessment of operative risk.

In the absence of a perfect quantitative score, the risk assessment should mostly rely on the clinical judgment of the ‘heart team”, in addition to the combination of scores.

Futility [fu‐til´ĭ‐te]: the quality of not leading to a desired result.

Medical futility: the judged futility of medical care, used as a reason to limit care.

TAVI futility: Inability to survive one year despite TAVI.

Majority of erderly patients with AS should be treatedwith surgical AVR with good clinical outcome expected.

Subset of extreme and high risk elderly patients, aftercarefull Heart Team evaluation should undergo TAVI, in selected cases with BAV as a brigde treatment .

Invasive treatment of elderly patients with extensivecomorbidities combined with frailty should be regardedas futile and is to be avoided.

Conclusions

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