Functional continuum: independent predictor of one-year mortality and key decision-making element in older adults with severe aortic stenosis amenable to aortic valve replacement

Abstract

Objectives: The impact of functional capacity over the entire functional continuum in older adults undergoing aortic valve replacement (AVR) has not been studied to date. This study aims to analyze 1.- the distribution of a cohort of older adults presenting severe aortic stenosis (AS) amenable to AVR in the different categories of the Functional Continuum Scale (FCS); 2.- its association with decision-making regarding valve disease; and 3.- its impact upon the one-year mortality rate of surgical (SAVR), transcatheter (TAVR) aortic valve replacement, or the decision to provide conservative management (OMT).

Methods: This prospective study included patients from the FRESAS (FRailty-Evaluation-in-Severe-Aortic-Stenosis) registry evaluated by the reference Heart-Team of a region in northern Spain. All the patients underwent comprehensive geriatric assessment.

Results: The study comprised 257 patients aged 84.0 ± 3.9 years.

Management: SAVR: 25.3%, TAVR: 58.0% and OMT: 16.7%. Increased patient functional capacity was associated with an increased tendency to perform more invasive valve disease treatment. The overall one-year survival rate was 81.3%. One-year all-cause mortality: FCS-1 to FCS-2 "robust" 11.5%, FCS-3 to FCS-4 "prefrail" 14.7%, FCS-5 "frail" 19.2% and FCS-6 to FCS-8 "dependent" 45.0%; p < 0.001. Adjusted mortality analysis: FCS with HR = 1.206 [95%CI, 0.999-1.451 (p = 0.051)]; EuroSCORE-II with HR = 1.071 [95%CI, 1.006-1.161 (p = 0.033)]; and OMT with HR = 2.840 [95%CI, 1.409-5.772 (p = 0.004)] were retained in the final multivariable logistic regression model.

Conclusions: In older AS patients amenable to AVR, the FCS is a useful predictive tool that may aid clinical decision-making.

Keywords: Aortic stenosis; Aortic valve replacement; Frailty; Functional continuum; Mortality.