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

2. 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 Fried JAMA Martinez-Selles Eur Heart J 2003 2 2

3. 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]:

4. 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]:

5. 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 Martínez-Sellés Int J Cardiol Iung Eur Heart J 2005 5 5

6. 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

7. 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

8. 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

9. 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

10. Comorbidity % AF Renal LVEF<0.5 COPD Stroke Cancer Demencia Disease10 10

11. 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

12. Main reason against indicating AVR (684 pts)12 12

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

14. 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

15. 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 ( ; p=0.002)
TAVI HR 0.68 ( ; p=0.016)
Intervention, PS adjusted:
AVR HR 0.38 ( )
TAVI HR 0.29 ( )
AVR
TAVI
Martínez-Sellés, Eur Heart J 2012 [abst]
Conservative
Patients at risk
AVR
TAVI
Conservative 15 15

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

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

18. 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

19. Contact information
Manuel Martínez-Sellés, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón.
Calle Dr. Esquerdo, 46; – Madrid, Spain
Tel ; fax 19 19