Preinterventional frailty assessment in patients scheduled for cardiac surgery or transcatheter aortic valve implantation: a consensus statement of the EACTS/ EAPC of the ESC
Introduction
In an ageing population of patients with heart disease, preinterventional frailty assessment for risk prediction is gaining relevance both in cardiac surgery and transcatheter valve interventions like transcatheter aortic valve implantation (TAVI). However, there is to date no consensus or widely accepted recommendations on how to determine frailty for prediction of outcomes of cardiovascular operations or interventions despite an exponentially growing number of studies in this field. Adding frailty assessment to conventional risk scores for cardiovascular interventions began in the context of heart-team discussions when TAVI for patients with aortic valve stenosis became an alternative for surgical aortic valve replacement (SAVR) [1]. Validated algorithms such as the EuroSCORE II [2] and the Society of Thoracic Surgeons (STS) Risk Score [3, 4] are usually used to estimate the perioperative risk of surgical procedures. They predominantly assess the risk of short-term mortality. For the decision between treatment modalities (surgery vs transcatheter procedure), this is not always sufficient because the typical patient population comprises elderly patients with a complex panel of comorbidities, physiological particularities and age-related risk factors. Therefore, risk assessment must take into account more and different factors than those considered in younger patients. For example, the above-mentioned scoring systems just include the chronological ages of the patients. Consequently, they tend to overestimate the perioperative risk of otherwise resilient elderly patients and, on the other hand, tend to underestimate the risk of patients who have lower resistance against stressors like a cardiac intervention or an operation. Additionally, frailty is accompanied by other patient-related factors like a decline in quality of life (QoL). Today, SAVR and TAVI are complementary techniques for the treatment of severe aortic stenosis with comparable short and mid-term outcomes according to several randomized controlled trials. Due to the remaining uncertainties concerning long-term (>5 years) TAVI valve durability, SAVR remains the preferred therapy in younger patients (<75 years of age) who are low risk for surgery (STS PROM or EuroScore II ≤4%) according to current European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines [5]. Usually, the end points that are mainly taken into consideration are short-term mortality and neurological complications like stroke. Softer end points like QoL are handled as a lower priority. This approach is in contrast to patients’ growing demands for prediction of their postoperative or postinterventional QoL and independent living situation. However, conventional risk scores are not validated for these end points. Frailty assessment is an additional factor for estimating the outcome of surgery or interventions in elderly patients who are low risk based on conventional risk scoring and can thus sharpen the estimation of the individual patient’s risk for an unfavourable outcome. A growing body of literature is available investigating frailty assessment as a predictor for the above-mentioned end points. Unfortunately, the literature is very heterogeneous. Maybe because of this lack of consistency, assessment tools are not routinely used in daily clinical routine. As a result, the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Preventive Cardiology (EAPC) decided to make an effort to review the available literature and to condense major findings in order to develop EACTS/EAPC consensus statements. Because the available literature is extensive and inconsistent, the members of the working group decided to limit the recommendations to surgical procedures and TAVI in order to maintain some clarity. Of course, there is also literature on frailty assessment related to other transcatheter interventions such as transcatheter edge-to-edge mitral valve repair. We propose to apply the recommendations in this consensus statement to these patient groups as well, because they are similar cohorts within the same risk group as TAVI patients.