The Spanish Data Bank PEGASO M. Martínez-Sellés The author has no conflict of interest Hospital Gregorio Marañón and Universidad Europea de Madrid, Spain

Background Aortic Stenosis (AS) Valve area Severe AS: frequent in the elderly, prevalence at 85 years>8%1 Predictor of mortality >65 years2 and in heart failure pts3 1Lindroos JACC 1995 2Fried JAMA 1998 3Martinez-Selles Eur Heart J 2003 2 2

Prognosis of Symptomatic AS Mortality after onset of symptoms is 50% at two years and 80% at five years Ross J Jr. Braunwald E: Aortic stenosis. Circulation 38[Suppl V]:61. 1968

Prognosis of Symptomatic AS Mortality after onset of symptoms is 50% at two years and 80% at five years Natural History studies included no (or few) octogenarians Bouma Heart 1999 Ross J Jr. Braunwald E: Aortic stenosis. Circulation 38[Suppl V]:61. 1968

Introduction Aortic valve replacement (AVR): preferred treatment for severe symptomatic AS1 But elderly pts are frequently managed medically Transcatheter aortic-valve implantation (TAVI) is a new option for high risk pts 30% H. Gregorio Marañón 130 pts 80 y2 33% EuroHeart Survey 216 pts 75 y3 1. Vahanian Eur Heart J 2012 2. Martínez-Sellés Int J Cardiol 2007 3. Iung Eur Heart J 2005 5 5

Scores EuroSCORE (additive, logistic, new) American Society of Thoracic Surgeons (STS) Parsonnet / Bernstein-Parsonnet Ontario Province Newark Beth Israel Medical Center ACC/AHA UK Society of Cardiothoracic Surgeons Higgins score French score The North West Regional Cardiac Surgery Audit Steering Group Cleveland Clinic Pons model Working Group Panel on the Cooperative CABG Database Project Acute Physiology and Chronic Health Evaluation (APACHE) Simplified Acute Physiology Score (SAPS) Mortality Probability Models (MPM) Edinburgh Cardiac Surgery Score survival prediction Cardiac Anesthesia Risk Evaluation (CARE) 6 6

AVR Risk increases with age AVR: AgeEuroSCORE Área bajo curva Area under the curve % Age Wendt. Interactive CardioVascular and Thoracic Surgery 2010 7 7

Aim To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic AS National prospective registry that included patients aged ≥80 y. with severe symptomatic AS Methods 8 8

Results 928 pts, 84.2±3.5 years, 58.8% women Only 49.0% were independent (Katz index A) Planned management: Results AVR Conservative TAVI 9 9

Comorbidity % AF Renal LVEF<0.5 COPD Stroke Cancer Demencia Disease 10 10

Baseline characteristics Conservative (n=423) TAVI (n=261) AVR (n=244) p-value Age (year) 85.1 ± 3.8 84.7 ± 3.3 82.2 ± 2 <0.001 Myocardial infarction 67 (15.8%) 33 (12.6%) 19 (7.8%) 0.011 Atrial fibrillation 145 (34.3%) 82 (31.4%) 57 (23.4%) 0.012 HF hospitalization 140 (51.9%) 119 (59.5%) 45 (34.1%) COPD 62 (14.7%) 58 (22.2%) 28 (11.5%) 0.003 Dementia 47 (11.1%) 10 (3.8%) 3 (1.2%) Katz index = A 164 (38.8%) 124 (47.5%) 170 (69.7%) Charlson index  3.3 ± 1.8 3.1 ± 1.6 2.4 ± 1.5 EuroSCORE  33.3 ± 17.4 31.4 ± 17.9 20.9 ± 13.1 Maximum gradient 74.1 ± 24.1 84.2 ± 20.9 85.5 ± 22.3 Ejection Fraction 57.5 ± 13.9 57 ± 13.2 61.7 ± 11 PA pressure 50.8 ± 16.2 53.6 ± 15.4 45.1 ± 14.1 Moderate Hypertrophy 273 (64.5%) 197 (75.5%) 176 (72.1%) 0.006 Other severe valve dis. 69 (16.3%) 19 (7.3%) 20 (8.2%) Haematocrit 36.9 ± 5.3 36.6 ± 5.3 38.2 ± 5 0.002 Creatinine clearance 40.4 ± 17.5 40.2 ± 15.1 50.1 ± 16.6 11 11

Main reason against indicating AVR (684 pts) 12 12

Predictors of non-AVR OR (95% CI) p Age (year) 1.3 (1.2-1.4) <0.001 Katz Index (level) 1.5 (1.3-1.7) EuroSCORE (%) 1.02 (1.01-1.04) LVEF≤0.4 2.0 (1.1-3.7) 0.048 Max. Gradient (mmHg) 0.99 (0.98-0.99) sPAP (mmHg) 1.03 (1.01-1.05) <0.001 13 13

10 death before intervention 16 death before intervention 357 pts (38.5%) died during follow-up (11.2 to 38.9 months, mean 15.6) Patient flow 244 AVR planned mortality rate: % in circles 62 conservative 19 TAVI 163 AVR 5.3% 14.1% 10 death before intervention 52 decision change 100% 30.8% 261 TAVI planned 59 conservative 190 TAVI 20.5% 12 AVR 41.7% 16 death before intervention 43 decision change 100% 48.8% 423 conservative planned 390 conservative 55.9% 17 TAVI 16 AVR 11.8% 37.5% Time from treatment decision to AVR 4.8±4.6 months, to TAVI 2.1±3.2, p<0.001 14 14

357 pts (38.5%) died during follow-up (11.2 to 38.9 months, mean 15.6) Planned intervention, adjusted for propensity score, was associated with lower mortality: AVR HR 0.56 (0.39-0.8; p=0.002) TAVI HR 0.68 (0.49-0.93; p=0.016) Intervention, PS adjusted: AVR HR 0.38 (0.25-0.59) TAVI HR 0.29 (0.20-0.42) AVR TAVI Martínez-Sellés, Eur Heart J 2012 [abst] Conservative Patients at risk AVR 244 217 170 110 51 25 9 TAVI 261 214 170 101 45 11 6 Conservative 423 328 232 154 70 25 9 15 15

Longevity Q of Life Melhorar a sobrevivência Melhorar a qualidade de vida Longevity Q of Life

Independence (Katz index) Death A B >B Unknown 100 80 60 % 40 20 Baseline 1 year 2 years Baseline 1 year 2 years Baseline 1 year 2 years Conservative TAVI AVR 17 17

Octogenarians with severe symptomatic AS are frequently managed conservatively Planned conservative management is associated with poor prognosis TAVI could be an excellent option in many octogenarians Take into account: Conclusions patient preferences procedure risk frailty and comorbidity QofL and life expectancy 18 18

Contact information Manuel Martínez-Sellés, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón. Calle Dr. Esquerdo, 46; 28007 – Madrid, Spain mmselles@secardiologia.es Tel. +34915868687; fax +34915868276 19 19