Age and Outcomes in TAVR Patients: Are We Barking Up the Wrong Tree?

We read with great interest the recent analysis from the prospective Swiss-TAVI Registry by Attinger-Toller et al.(1) The authors described a linear relationship between increasing age and prevalence of all-cause mortality, stroke and pacemaker implantation after transcatheter aortic valve implantation (TAVI). For their purpose, they divided patients into four groups based on age (< 70, 71-79, 80-89, > 90) and investigated the occurrence of all-cause mortality at 1 year as well as of a series of secondary endpoints (1). However, the clinical application of this important finding is controversial. Age is a gross estimate of patients’ both clinical condition and risk. In addition, it is not actionable. Therefore, it is unlikely to be utilized per se as gatekeeper for TAVI eligibility, especially for older patients with no feasible alternative. On the contrary, frailty, whose occurrence is linearly correlated with age, has been demonstrated as a major driver of prognosis after TAVI (2) and most of its substrates, such as malnutrition and inactivity, are actionable. To this end, it has been recently showed that frail patients undergoing radial balloon aortic valvuloplasty and a subsequent prehabilitation program aimed at frailty reduction, were able to improve both their frailty level at the time of TAVI and their prognosis afterwards (3). Therefore, improving frailty status before TAVI could be the right way to ameliorate the clinical outcome, especially in older patients. Further randomized trials are needed to confirm this hypothesis.