You know, the landscape of aortic valve stenosis has really changed over time where prior to this we were seeing a lot of rheumatic heart disease and now what we're seeing is a lot of calcific degenerative aortic stenosis and because the technology has really improved for patients with congenital heart disease, we are also seeing more patients who have bicuspid valves and with calcific degeneration. The prevalence of valvular heart disease really increases with age and really that we see that upslope after the age of 65 and if we focus on aortic stenosis, compared to patients who are less than 60 years of age where you have approximately a 0.2% prevalence of aortic stenosis, those who are above 90 years of age, there's a 17% prevalence. And so what about these nonagenarians that we're beginning to see? You know, from 1995 to 2020, there has been an increase of nonagenarians from 6.4 million people worldwide to now 21 million worldwide and by 2050, it's projected that 76 million nonagenarians will exist in the world where 8 million of those will be in the U.S. And because there has been no proven therapy to prevent aortic stenosis really, the number of these oldest old patients with aortic stenosis is expected to mirror this demographic population trend. You know, obviously, it's been shown that the therapeutic option for patients with severe symptomatic aortic stenosis, especially if you're a prohibitive and high risk, obviously now an intermediate and low surgical risk, the option for treatment is TAVR. And over, you know, the course of the years, the number of patients who are being treated with TAVR over the age of 90 has progressively increased as well where we're seeing approximately one in every seven TAVRs in the U.S. is performed in someone who's a nonagenarian. Historically, these patients have been excluded from the surgical realm mainly because of their age and the thoughts were of them having multiple comorbidities. But this patient population was not excluded from the initial TAVR trials such as the partner trials. And therefore, you know, as clinicians, we're now tasked with this ability to have to identify what is the good 90-year-old. And so there was a study that was done, a registry analysis from the Swiss TAVI between February 2011 and June 2018 where they looked at 7,000 patients that they had done TAVRs on and what they saw was that two-thirds of their patients was in this 80 to 89-year range, but only 5% of their 7,000 patients were the patients above 90 years of age. And so what is so special about these nonagenarians, you know, they're really surpassing this life expectancy by more than a decade. And so the thought process is they have what's called this healthy survivor effect where, you know, clinicians thought that they would have more comorbidities, but if you think about it, they've been surviving, so they have lower rates of comorbidities. However, when you do see a patient in your clinic who has severe aortic stenosis, they are likely to have at least one significant comorbidity where chronic kidney disease is leading that, followed by diabetes, having a history of MI, dementia, or a prior stroke. And so this apprehension that clinicians usually have to perform invasive procedures on greater than patients who are 90 years of age, where is that coming from? Is it the chronological age which is an issue or is frailty really a better indicator of what's biological aging? You know, that thought that if someone who is greater than 90 would have all of these comorbidities, but that is not necessarily the case where you have someone who could be in their 70s and have multiple accumulated deficits versus someone who's 95 years and just has a history of diabetes. So what are we seeing? The nonagenarians who do undergo TAVR and who you decide that, you know, they're what's called a good 90-year-old, they're also most likely to present with multivalve disease, not necessarily their comorbidities, but having more than one valve involved besides their severe aortic stenosis and particularly mitral regurgitation. So someone who has symptomatic severe aortic stenosis also presenting with moderate to severe MR, what we're seeing is a twofold increase in mortality post-TAVR. And in a multicenter prospective cohort study by Arsalan, the team has found that 81% of patients who are nonagenarians going for their symptomatology is New York Heart Association class III and IV symptoms and an average KCCQ of about 42. And after the TAVR has been performed, there has been found to have a significant improvement in that average KCCQ score of 75, much like the general population. There was a meta-analysis that was performed that looked at 22 observational studies that involved about 10,000 of these more than 90-year-old patients, and what they found was that at a 30-day mortality rate, post-TAVR was approximately 5.5%. Likewise, another meta-analysis of 12 of those observational studies, which involved 6,500 nonagenarians, the one-year mortality rate post-TAVR increased to about 23%. However, what needs to be said about this population is that that percent, that one-year mortality, was not drastically significantly different compared to nonagenarians in the general population. So how do we make good use of TAVR? You know, just going back to the original partner trial, when they looked, you saw like two different cohorts, Cohort A, which were patients who were high-risk but operable. Cohort B patients were the ones that were studied where there was inoperable patients, and what was considered inoperable were not just patients by their clinical aspect but also anatomically. So someone who has porcelain aorta, for instance, chest radiation, chest wall deformity, these were patients that were seen. But there was a third cohort, Cohort C, which were patients who are not just inoperable but had the very serious comorbidities. And what were those? Those include really…they were really frail, malnutrition, cachexic, maybe have recent malignancy, stroke, dementia, and dialysis. And so the thought is that returning to a semi-independent living and lifestyle would be very unlikely in this TAVR…in this TAVR…in this population if they proceeded with TAVR. So how do we…like who do we choose and how do we choose for TAVR and the elderly patients? So some of these questions that you…to consider for patient selection, one is like looking at the short-term risks. Is this patient who's over 90 years old or over 80, 90 years old, are they at risk for a major procedural complication such as are they someone that can't do the traditional transfemoral approach? Do they have to have alternative access? Likewise, from in the midterm recovery part, is it someone you have to think of? Can they return home? Are they able to recover their function following the TAVR or are they going to end up going to a nursing home? You know, you have to look at, again, frailty is a big thing. Do they have poor social support? Are they actively depressed? You know, as they…as patients get older and they have to take more medication, is that something that we have to consider? And then…and then when you look at the overall picture, what are the long-term benefits? Is this patient going to have a meaningful life…longevity or lifestyle, be able to go home? Is their quality of life going to improve after they have a TAVR or are they someone like…have these major comorbidities such as advanced dementia, bed-bound, cachexic? And then overall, this is the big…big take-home is to have the discussion with the patient and their family. Do they understand the expected benefits? Do the risks outweigh those benefits? And do they even want to proceed to have an invasive procedure? And you have to realize, are they going to have unrealistic expectations? And again, some of the things that they have, they'll have multivalvular disease. So even if you take away the severe aortic stenosis, if they're left with moderate to severe or more than severe MR that's not amenable to any percutaneous aspects, are they going to think that they're suddenly not going to have shortness of breath anymore? Are they going to be more functional? So these are the questions that we have to think about when we're choosing who to do TAVRs in the elderly population. So in summary, you know, this subset of patients, particularly patients who are above 90 years of age, they have been underrepresented or at least very highly selected in the randomized controlled trials. And as we can see with the trend, as the population increases, we are going to see more patients who are nonagenarian, oxygenarian with severe aortic stenosis. And those are patients that we're going to have to consider treating and not miss them because they could be 90, they could live until they're 96. Nonagenarians paradoxically have greater resilience, less healthy survivors, fewer comorbidities. So age alone is not adequate for risk stratification. And frailty is really something that's very revealing. And again, we have to look at, is the patient coming in with multivalvular disease because of the increase in mortality post-TAVR. And what's always key, lastly, is shared decision-making with the patient and the patient's family.

aortic valve stenosis

TAVR

nonagenarian patients

patient selection

mortality rates

aortic

TAVI