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      Do frailty measures improve prediction of mortality and morbidity following transcatheter aortic valve implantation? An analysis of the UK TAVI registry

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          Abstract

          Objectives

          Previous studies indicate frailty to be associated with poor outcomes following transcatheter aortic valve implantation (TAVI), but there is limited evidence from multicentre registries. The aim was to investigate the independent association of frailty with TAVI outcomes, and the prognostic utility of adding frailty into existing clinical prediction models (CPMs).

          Design

          The UK TAVI registry incorporated three frailty measures since 2013: Canadian Study of Health and Ageing, KATZ and poor mobility. We investigated the associations between these frailty measures with short-term and long-term outcomes, using logistic regression to estimate multivariable adjusted ORs, and Cox proportional hazards models to explore long-term survival. We compared the predictive performance of existing TAVI CPMs before and after updating them to include each frailty measure.

          Setting

          All patients who underwent a TAVI procedure in England or Wales between 2013 and 2014.

          Participants

          2624 TAVI procedures were analysed in this study.

          Primary and secondary outcomes

          The primary endpoints in this study were 30-day mortality and long-term survival. The Valve Academic Research Consortium (VARC)-2 composite early safety endpoint was considered as a secondary outcome.

          Results

          KATZ <6 (OR 2.10, 95% CI 1.39 to 3.15) and poor mobility (OR 2.15, 95% CI 1.41 to 3.28) predicted 30-day mortality after multivariable adjustment. All frailty measures were associated with increased odds of the VARC-2 composite early safety endpoint. We observed a significant increase in the area under the receiver operating characteristic curves by approximately 5% after adding KATZ <6 or poor mobility into the TAVI CPMs. Risk stratification agreement was significantly improved by the addition of each frailty measure, with an increase in intraclass correlation coefficient of between 0.15 and 0.31.

          Conclusion

          Frailty was associated with worse outcomes following TAVI, and incorporating frailty metrics significantly improved the predictive performance of existing CPMs. Physician-estimated frailty measures could aid TAVI risk stratification, until more objective scales are routinely collected.

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          Most cited references 22

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          Regression with missing Ys: An improved strategy for analyzing multiply imputed data

          When fitting a generalized linear model -- such as a linear regression, a logistic regression, or a hierarchical linear model -- analysts often wonder how to handle missing values of the dependent variable Y. If missing values have been filled in using multiple imputation, the usual advice is to use the imputed Y values in analysis. We show, however, that using imputed Ys can add needless noise to the estimates. Better estimates can usually be obtained using a modified strategy that we call multiple imputation, then deletion (MID). Under MID, all cases are used for imputation, but following imputation cases with imputed Y values are excluded from the analysis. When there is something wrong with the imputed Y values, MID protects the estimates from the problematic imputations. And when the imputed Y values are acceptable, MID usually offers somewhat more efficient estimates than an ordinary MI strategy.
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            The impact of frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis: a single-center experience.

            This study sought to evaluate the impact of frailty in older adults undergoing transcatheter aortic valve replacement (TAVR) for symptomatic aortic stenosis. Frailty status impacts prognosis in older adults with heart disease; however, the impact of frailty on prognosis after TAVR is unknown. Gait speed, grip strength, serum albumin, and activities of daily living status were collected at baseline and used to derive a frailty score among patients who underwent TAVR procedures at a single large-volume institution. The cohort was dichotomized on the basis of median frailty score into frail and not frail groups. The impact of frailty on procedural outcomes (stroke, bleeding, vascular complications, acute kidney injury, and mortality at 30 days) and 1-year mortality was evaluated. Frailty status was assessed in 159 subjects who underwent TAVR (age 86 ± 8 years, Society of Thoracic Surgery Risk Score 12 ± 4). Baseline frailty score was not associated with conventionally ascertained clinical variables or Society of Thoracic Surgery score. Although high frailty score was associated with a longer post-TAVR hospital stay when compared with lower frailty score (9 ± 6 days vs. 6 ± 5 days, respectively, p = 0.004), there were no significant crude associations between frailty status and procedural outcomes, suggesting adequacy of the standard selection process for identifying patients at risk for periprocedural complications after TAVR. Frailty status was independently associated with increased 1-year mortality (hazard ratio: 3.5, 95% confidence interval: 1.4 to 8.5, p = 0.007) after TAVR. Frailty was not associated with increased periprocedural complications in patients selected as candidates to undergo TAVR but was associated with increased 1-year mortality after TAVR. Further studies will evaluate the independent value of this frailty composite in older adults with aortic stenosis. Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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              Frailty in Older Adults Undergoing Aortic Valve Replacement

              Frailty is a geriatric syndrome that diminishes the potential for functional recovery after a transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) procedure; however, its integration in clinical practice has been limited by a lack of consensus on how to measure it.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2018
                30 June 2018
                : 8
                : 6
                Affiliations
                [1 ] departmentFarr Institute, Faculty of Biology, Medicine and Health , University of Manchester, Manchester Academic Health Science Centre , Manchester, UK
                [2 ] Queen Elizabeth Hospital , Birmingham, UK
                [3 ] The James Cook University Hospital , Middlesbrough, UK
                [4 ] departmentKeele Cardiovascular Research Group, Institute of Applied Clinical Science and Centre for Prognosis Research Group , Institute of Primary Care and Health Sciences, Keele University , Stoke-on-Trent, UK
                [5 ] departmentAcademic Department of Cardiology , Royal Stoke Hospital , Stoke-on-Trent, UK
                [6 ] Guy’s and St Thomas’ NHS Foundation Trust , London, UK
                [7 ] Microsoft Research , Cambridge, UK
                Author notes
                [Correspondence to ] Dr Glen P Martin; glen.martin@ 123456manchester.ac.uk
                Article
                bmjopen-2018-022543
                10.1136/bmjopen-2018-022543
                6042628
                29961038
                © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

                This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

                Product
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000265, Medical Research Council;
                Categories
                Cardiovascular Medicine
                Research
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