**4. Frailty and geriatric evaluation of octogenarians for SAS management**

#### **4.1 Frailty**

176 Aortic Valve Surgery

The results of some studies showed that the postoperative and short-term outcomes were worse for patients treated with TA than TF access, because the former were more severely ill and had more severe comorbidities. The Logistic EuroSCORE predicted risk was significantly higher for TA than TF, respectively: 35% vs 25% (p=0.01), as did STS-PROM 10.3% vs 8.7% (Webb et al., 2009). In-hospital mortality was 8% for the TF group vs 27% for TA group, with respective 1-year survival rates of 74±11% vs 60±13% (Al-attar et al., 2009). At 1 year, the European PARTNER study results were comparable (Lefèvre et al., 2011).

TAVI development has highlighted the complexity of risk assessment and patient selection. At present, TAVI is indicated only for SAS patients ineligible for conventional AVR, but the definition of "ineligible" remains vague. TAVI was initially designed to treat old-old patients, mean age 81–86 years (Bleiziffer et al., 2009; Tamburino et al., 2011), with high Logistic EuroSCORE predicted risk ≥20%, mean range 22–29% (Grube et al., 2007; Webb et al., 2009) or STS-PROM score ≥10%, mean range 16–23% (Al-attar et al., 2009; Bleiziffer et al.,

Logistic EuroSCORE and STS-PROM scores are increasingly being used to estimate operative mortality based on cardiac and extracardiac factors. The STS-PROM score appears to be more reliable than the EuroSCORE for predicting outcomes of high-risk AVR patients. However, STS-PROM tends to underestimate mortality (Dewey et al., 2007). A meta-analysis showed EuroSCORE to have low discrimination ability for valve surgery and it slightly over predicted risk (Parolari et al., 2010), particularly for octogenarians referred for AVR (Leontyev et al., 2009). Both scores share the same limitations: predictive ability is limited for high-risk patients, who represented only a small proportion of the population used to derive them. They do not take into account the surgical results in a given institution, relationship between volume and mortality, and the impact of progress concerning surgical techniques, cardiopulmonary bypass, anesthesia and intensive care. The scores also fail to evaluate fully the high-risk patient because they do not integrate a very important element: clinical judgment. Indeed, many factors that negatively influence prognosis are not considered: cirrhosis, impact of body mass index, chest irradiation, chest deformation, multivalve surgery, porcelain aorta, previous CABG and vascular tortuosity for TAVI. It is estimated that neither the Logistic EuroSCORE nor STS-PROM would have classed approximately one-quarter of the patients at high risk and yet they were refused surgery because of such

For the specific SAS octogenarian population, it seems that the development of a new specific scoring classification is necessary (Florath et al., 2010), especially one including

TAVI is not suitable for all patients ineligible for conventional AVR and patients referred for TAVI are also highly selected. In a cohort of 469 SAS patients referred for participation in a TAVI trial, 362 (77.1%) patients did not meet the inclusion/exclusion criteria. The main exclusion criteria were low STS-PROM score <10% (72 patients), peripheral vascular or aorta disease (58 patients), aortic valve area >0.8 cm2 (54 patients), significant coronary artery disease (43 patients) and renal failure (25 patients). Among those 362 patients, 75 (20.7%) had 2 exclusion criteria and 26 (7.1%) had 3 exclusion criteria. Eighty-eight patients

demographic variables, such as nutritional status, disability, dementia and frailty.

**3.3 Risk assessment and patient selection** 

2009) or with contraindication(s) for surgery.

factors (Webb et al., 2009).

**3.4 Unanswered questions concerning TAVI** 

To evaluate better an individual's situation on which the final therapeutic decision generally depends, the concepts of frailty or vulnerability are the themes of several international gerontology publications. We highlight that, at present, no consensual definition of frailty exists (Bergman et al., 2007; Karunananthan et al., 2009). However, the various authors agree that frailty is a state of susceptibility to aggression, which explains that, for a given health event, despite the same management and apparently sufficiently similar health status, the individuals will have very different outcomes. Thus, frailty is always defined as a function of the event that serves as the judgement criterion: falls, loss of autonomy, institutionalization, death… It is also defined by the time at which it is assessed. Therefore, an effective definition over the long term (Province et al., 1995) might not be operative to distinguish individuals in terms of consequences of hospitalization (Gill et al., 2004).

Regardless of the definition retained, the authors defined a certain number of common characteristics (Rockwood, 2005): frailty is a continuous state that is not simply present or absent; it is not the consequence of single organ involvement; the clinical manifestations are multiple. It can be recognized clinically, with that identification being considered the threshold of entry into frailty, the occurrence of the negative event marking the end of frailty in relationship to this factor (institutionalization or handicap, for example). The definitions of frailty are multiple (Ferrucci et al., 2004), but the most used are those that refer to the diminished physiological reserves, with a core event being the development of sarcopenia. This type of definition has shown its efficacy to predict the loss of autonomy, institutionalization or death in a cohort of patients with cardiovascular diseases but not initially handicapped and followed for 1 year (Fried et al., 2004). Its effect can be associated

Relationship Between Aortic Valve Replacement and Old Age 179

were based on large majorities of patients (>60%) who underwent simple coronary artery bypass surgery. Even though the type of intervention was entered into the model, the phenotype's effect on valve-surgery complications (and even more so for the newer interventional techniques) warrants further clarification. The models currently used in cardiac surgery are mainly based on the frailty–sarcopenia concept. The contributions of other frailty dimensions to explaining outcome (biological, psychological, environmental and social) are also worthy of more detailed exploration. Finally, the available studies focused on subjects who were certainly old (>70 years), but the usefulness of the scores and the thresholds applied undoubtedly need to be adapted for the oldest–old (>85–90 years).

All of the above underscore the complexity of decision-making and follow-up of the oldestold when AVR becomes necessary, and support an interdisciplinary approach bringing together cardiologists, surgeons, geriatricians, anesthesiologists and intensivists. However, convincing data on the impact of a geriatric approach in this setting are still lacking. The geriatrician is most probably in an ideal position, in terms of professional competence, to detect frailty, but the impact of this identification on the decisions to be made and, even more so, on the outcomes are not yet documented. As we have seen, it is also likely that the consequences of cardiac surgery, beyond its cardiovascular impact, are multidimensional (Maillet et al., 2009). It seems highly probable that an overall approach, like that proposed by geriatricians in another context (Rydwik et al., 2008), would contribute to improving the outcomes of individuals, not only in functional terms but also nutritional, psychological,

Rehabilitation after cardiac surgery is not less effective in the elderly than young patients (Macchi et al., 2007; Pasquali et al., 2001) and improves the outcome, even though information on the oldest-old are scarce (Pasquali et al., 2001). Indeed, it seems, for the aged patient, that rehabilitation after cardiac surgery should not be postponed and should be prolonged (Macchi et al., 2009). This is especially true for women >80 years who achieve a gain in functional autonomy 1 year after the intervention (Barnett & Halpin, 2003). Some authors recommend particular preoperative precautions, notably respiratory. The preoperative identification of frail patients could also be a pertinent way to select patients likely to benefit the most from specific programs, e.g., early mobilization in the intensive care unit (Needham, 2008). Multidimensional rehabilitation programs also achieved favorable results (Eder et al., 2010; Mazza et al., 2007; Opasich et al., 2010), which, in addition, proved their safety and efficacy in terms of rehabilitation, nursing needs, mobility capability, muscle

Surgical AVR for SAS in octogenarians is the treatment of choice and is performed daily, with good intermediate-term results, despite high postoperative morbidity. In the very near future, TAVI should profoundly modify the treatment strategy for SAS. Despite all the improvements since the beginning of cardiac surgery, much progress remains to be achieved in all the steps: improving patient selection, more accurately stratifying the risks, choosing the best treatment, limiting morbidity regardless of the technique used, and

**4.3 Contribution of geriatric evaluation to AVR decision-making** 

force, equilibrium and, last but certainly no least, duration of stay.

social and even cognitive aspects.

**4.4 Adapted rehabilitation** 

**5. Conclusion** 

with those of a disability and comorbidity, even though none of these 3 dimensions is superimposable or sufficient alone to explain the outcome (Fried et al., 2004).

According to those authors' definition (Fried et al., 2004), at least 3 criteria among the following must be satisfied to be qualified as 'fragile': diminished gripping force of the dominant hand, the feeling of fatigue/exhaustion, slower walking speed and nonintentional weight loss. Each of the elements is evaluated according to precise criteria. Such a definition could prove useful to study the long-term outcome of patients after cardiac surgery. In addition, this type of definition conceptually excludes the cognitive, sociofamilial and psychological dimensions of frailty (Fried et al., 2004). To take those dimensions into account, 2 types of solutions are proposed: an inventory of the situations at risk that can be extremely complex and overall clinical judgment, whose pertinence concerning loss of autonomy and death were recently validated (Jones et al., 2005).

#### **4.2 Frailty and cardiac surgery**

The concept of frailty and its clinical use in surgery in general and, more specifically, cardiac surgery, has recently appeared in the literature. Two recent studies (Afilalo et al., 2010; Lee et al., 2010) documented that frailty increased the risk of complications after cardiac surgery independently of age and included information from standard prognostic scores. Pertinently, those 2 studies are complementary.

Indeed, Afilalo et al. (2010) defined frailty as requiring assistance to accomplish at least one essential life activity, a diagnosis known of dementia or limited mobility. Although their definition can be debated on a conceptual level, because it mixes disability and fragility, it has the advantage of being clinically operational. The existence of a frailty phenotype, as defined, was independently associated with mortality (OR 1.8 [95% CI 1.1–3.0]), institutionalization and discharge from that facility (OR 6.3 [95% CI 4.2–9.4]) and intermediate-term survival (OR 1.5 [95% CI 1.1–2.2]).

Lee et al. (2010) defined frailty more precisely and more sensitively: walking speed tested as a mean time needed to go 5 m during 3 consecutive tries (limited to 6 seconds). Their definition is directly in line with the conceptual frailty–sarcopenia model. In their study, the risk of postoperative morbidity–mortality was multiplied by 3.05 [95% CI 1.23–7.64] for frail patients, even after adjustment for the STS-PROM score. In addition, frailty defined in this way doubled the risk of institutionalization or a prolonged stay there. Finally, in a manner not entirely clear, the risks linked to frailty are greater for women than men.

The results of those studies confirmed the findings of others concerning non-cardiac surgery, i.e., that such a definition of frailty is associated with "geriatric syndromes" (Robinson et al., 2009), sarcopenia (Makary et al., 2010) or a more holistic score-based definition (Dasgupta et al., 2009). In all those cases, the frailty phenotype was independently associated with age and other known prognostic factors of higher risk of morbidity and/or mortality.

Only authors of rare studies have envisaged frailty's appearance as a surgical consequence. Researchers of a single center study supported that hypothesis and strongly recommended that the appearance of that phenotype should be considered in future outcome investigations because this fragility is linked even more strongly to QOL than self-reported overall assessments of "health status" (Maillet et al., 2009).

We would also like to underscore the areas of uncertainty that persist today and that represent as many research projects. Afilalo et al.'s (2010) and Lee et al.'s (2010) examinations of potential relationships between a frailty phenotype and outcomes after cardiac surgery

with those of a disability and comorbidity, even though none of these 3 dimensions is

According to those authors' definition (Fried et al., 2004), at least 3 criteria among the following must be satisfied to be qualified as 'fragile': diminished gripping force of the dominant hand, the feeling of fatigue/exhaustion, slower walking speed and nonintentional weight loss. Each of the elements is evaluated according to precise criteria. Such a definition could prove useful to study the long-term outcome of patients after cardiac surgery. In addition, this type of definition conceptually excludes the cognitive, sociofamilial and psychological dimensions of frailty (Fried et al., 2004). To take those dimensions into account, 2 types of solutions are proposed: an inventory of the situations at risk that can be extremely complex and overall clinical judgment, whose pertinence concerning loss of

The concept of frailty and its clinical use in surgery in general and, more specifically, cardiac surgery, has recently appeared in the literature. Two recent studies (Afilalo et al., 2010; Lee et al., 2010) documented that frailty increased the risk of complications after cardiac surgery independently of age and included information from standard prognostic scores. Pertinently,

Indeed, Afilalo et al. (2010) defined frailty as requiring assistance to accomplish at least one essential life activity, a diagnosis known of dementia or limited mobility. Although their definition can be debated on a conceptual level, because it mixes disability and fragility, it has the advantage of being clinically operational. The existence of a frailty phenotype, as defined, was independently associated with mortality (OR 1.8 [95% CI 1.1–3.0]), institutionalization and discharge from that facility (OR 6.3 [95% CI 4.2–9.4]) and

Lee et al. (2010) defined frailty more precisely and more sensitively: walking speed tested as a mean time needed to go 5 m during 3 consecutive tries (limited to 6 seconds). Their definition is directly in line with the conceptual frailty–sarcopenia model. In their study, the risk of postoperative morbidity–mortality was multiplied by 3.05 [95% CI 1.23–7.64] for frail patients, even after adjustment for the STS-PROM score. In addition, frailty defined in this way doubled the risk of institutionalization or a prolonged stay there. Finally, in a manner

The results of those studies confirmed the findings of others concerning non-cardiac surgery, i.e., that such a definition of frailty is associated with "geriatric syndromes" (Robinson et al., 2009), sarcopenia (Makary et al., 2010) or a more holistic score-based definition (Dasgupta et al., 2009). In all those cases, the frailty phenotype was independently associated with age and other known prognostic factors of higher risk of morbidity and/or

Only authors of rare studies have envisaged frailty's appearance as a surgical consequence. Researchers of a single center study supported that hypothesis and strongly recommended that the appearance of that phenotype should be considered in future outcome investigations because this fragility is linked even more strongly to QOL than self-reported overall

We would also like to underscore the areas of uncertainty that persist today and that represent as many research projects. Afilalo et al.'s (2010) and Lee et al.'s (2010) examinations of potential relationships between a frailty phenotype and outcomes after cardiac surgery

not entirely clear, the risks linked to frailty are greater for women than men.

superimposable or sufficient alone to explain the outcome (Fried et al., 2004).

autonomy and death were recently validated (Jones et al., 2005).

**4.2 Frailty and cardiac surgery** 

those 2 studies are complementary.

mortality.

intermediate-term survival (OR 1.5 [95% CI 1.1–2.2]).

assessments of "health status" (Maillet et al., 2009).

were based on large majorities of patients (>60%) who underwent simple coronary artery bypass surgery. Even though the type of intervention was entered into the model, the phenotype's effect on valve-surgery complications (and even more so for the newer interventional techniques) warrants further clarification. The models currently used in cardiac surgery are mainly based on the frailty–sarcopenia concept. The contributions of other frailty dimensions to explaining outcome (biological, psychological, environmental and social) are also worthy of more detailed exploration. Finally, the available studies focused on subjects who were certainly old (>70 years), but the usefulness of the scores and the thresholds applied undoubtedly need to be adapted for the oldest–old (>85–90 years).

#### **4.3 Contribution of geriatric evaluation to AVR decision-making**

All of the above underscore the complexity of decision-making and follow-up of the oldestold when AVR becomes necessary, and support an interdisciplinary approach bringing together cardiologists, surgeons, geriatricians, anesthesiologists and intensivists. However, convincing data on the impact of a geriatric approach in this setting are still lacking. The geriatrician is most probably in an ideal position, in terms of professional competence, to detect frailty, but the impact of this identification on the decisions to be made and, even more so, on the outcomes are not yet documented. As we have seen, it is also likely that the consequences of cardiac surgery, beyond its cardiovascular impact, are multidimensional (Maillet et al., 2009). It seems highly probable that an overall approach, like that proposed by geriatricians in another context (Rydwik et al., 2008), would contribute to improving the outcomes of individuals, not only in functional terms but also nutritional, psychological, social and even cognitive aspects.

#### **4.4 Adapted rehabilitation**

Rehabilitation after cardiac surgery is not less effective in the elderly than young patients (Macchi et al., 2007; Pasquali et al., 2001) and improves the outcome, even though information on the oldest-old are scarce (Pasquali et al., 2001). Indeed, it seems, for the aged patient, that rehabilitation after cardiac surgery should not be postponed and should be prolonged (Macchi et al., 2009). This is especially true for women >80 years who achieve a gain in functional autonomy 1 year after the intervention (Barnett & Halpin, 2003). Some authors recommend particular preoperative precautions, notably respiratory. The preoperative identification of frail patients could also be a pertinent way to select patients likely to benefit the most from specific programs, e.g., early mobilization in the intensive care unit (Needham, 2008). Multidimensional rehabilitation programs also achieved favorable results (Eder et al., 2010; Mazza et al., 2007; Opasich et al., 2010), which, in addition, proved their safety and efficacy in terms of rehabilitation, nursing needs, mobility capability, muscle force, equilibrium and, last but certainly no least, duration of stay.

#### **5. Conclusion**

Surgical AVR for SAS in octogenarians is the treatment of choice and is performed daily, with good intermediate-term results, despite high postoperative morbidity. In the very near future, TAVI should profoundly modify the treatment strategy for SAS. Despite all the improvements since the beginning of cardiac surgery, much progress remains to be achieved in all the steps: improving patient selection, more accurately stratifying the risks, choosing the best treatment, limiting morbidity regardless of the technique used, and

Relationship Between Aortic Valve Replacement and Old Age 181

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**11** 

*Spain* 

M. Paz Sanz-Ayan1, Delia Diaz1,

**Neurological Complications in Aortic Valve Surgery and Rehabilitation Treatment Used** 

*1Department of Rehabilitation, University Hospital 12 de Octubre, Madrid 2Department of Neurology, University Hospital 12 de Octubre, Madrid 3Department of Cardiac Surgery, University Hospital 12 de Octubre, Madrid* 

Around the second decade of the twentieth century there was speculation about the possibility of cardiac surgery and its possible consequences in the central nervous system. To reduce these potential consequences as much as possible, research was carried out into three different approaches: systemic hypothermia, by placing the patient in a bath of icecold water, cross circulation between two people, and cardiopulmonary bypass (CPB) with a roller pump and an artificial oxygenator (Clau Terré, 2009). Shortly after using these procedures, it became clear there was an advantage provided by the CPB technique with an independent oxygenator and normal systemic flows that neither cross-circulation nor surface hypothermia could provide. It thus became possible to address increasingly complex congenital heart disease and ventricular septal defects, tetralogy of Fallot and other more complex examples. With the introduction of CPB, early neurological complications such as

coma, cognitive impairment, strokes, etc. began to appear.

Fig. 1. Extracorporeal (CPB) blood pump

**1. Introduction** 

Antonio Martinez-Salio2, Francisco Miguel Garzon1, Carmen Urbaneja1, Jose Valdivia1 and Alberto Forteza3

