Malnutrition and Mortality in Frail and Non-Frail Older Adults Undergoing Aortic Valve Replacement
Background—Older adults undergoing aortic valve replacement are at risk for malnutrition. The association between pre-procedural nutritional status and midterm mortality has yet to be determined.
Methods—The FRAILTY-AVR prospective multi-center international cohort study was conducted between 2012-2017 in 14 centers in 3 countries. Patients ≥70 years of age who underwent transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) were eligible. The Mini Nutritional Assessment-Short Form (MNA-SF) was assessed by trained observers pre-procedure, with scores ≤7 of 14 considered malnourished and 8-11 of 14 considered at-risk for malnutrition. The Short Performance Physical Battery (SPPB) was simultaneously assessed to measure physical frailty, with scores ≤5 of 12 considered severely frail and 6-8 of 12 considered mildly frail. The primary outcome was 1-year all-cause mortality and the secondary outcome was 30-day composite mortality or major morbidity. Multivariable regression models were used to adjust for potential confounders.
Results—There were 1,158 patients (727 TAVR and 431 SAVR) with 45% females, a mean age of 81.3 years, a mean body mass index of 27.5 kg/m2, and a mean Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) of 5.1%. Overall, 8.7% of patients were classified as malnourished and 32.8% were at-risk for malnutrition. MNA-SF scores were moderately correlated with SPPB scores (Spearman R=0.31, P<0.001). There were 126 deaths in the TAVR group (19.1 per 100 patient-years) and 30 deaths in the SAVR group (7.5 per 100 patient-years). Malnourished patients had a nearly 3-fold higher crude risk of 1-year mortality compared with those with normal nutritional status (28% vs 10%, P<0.001). After adjustment for frailty, STS-PROM, and procedure type, pre-procedural nutritional status was a significant predictor of 1-year mortality (OR 1.08 per MNA-SF point, 95% CI 1.01-1.16) and of the 30-day composite safety endpoint (OR 1.06 per MNA-SF point, 95% CI 1.00 to 1.12).
Conclusions—Pre-procedural nutritional status is associated with mortality in older adults following aortic valve replacement. Clinical trials are needed to determine whether pre- and post-procedural nutritional interventions can improve clinical outcomes in these vulnerable patients.
- Received January 24, 2018.
- Revision received May 4, 2018.
- Accepted June 14, 2018.