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Circulation. 2018 Nov 13;138(20):2202-2211. doi: 10.1161/CIRCULATIONAHA.118.033887.

Malnutrition and Mortality in Frail and Non-Frail Older Adults Undergoing Aortic Valve Replacement.

Author information

1
Azrieli Heart Centre (M.G., L.G.R., J.A.), Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
2
Centre for Heart Valve Innovation, St Paul's Hospital, University of Vancouver, British Columbia, Canada (S.L., J.G.W.).
3
Division of Cardiology (A.W.A.), Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada.
4
Division of Cardiac Surgery (L.P.P.), Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada.
5
Division of Cardiology (N.P., G.M.), McGill University Health Centre, Montreal, Quebec, Canada.
6
Division of Cardiac Surgery (K.L.), McGill University Health Centre, Montreal, Quebec, Canada.
7
Division of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Centre de Recherche du CHUM, Montreal, Quebec, Canada (N.N.).
8
Division of Gerontology (D.H.K.), Beth Israel Deaconess Medical Center, Harvard University, Boston, MA.
9
Division of Cardiology (J.J.P.), Beth Israel Deaconess Medical Center, Harvard University, Boston, MA.
10
Division of Cardiology, Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France (T.L.).
11
Division of Cardiology, University of Ottawa Heart Institute, Ontario, Canada (M.L.).
12
Division of Cardiac Surgery, Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (A.L.).
13
Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada (M.D.P.).
14
Section of Cardiac Surgery, Max Rady College of Medicine, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada (R.C.A.).
15
Division of Geriatric Medicine (J.A.M.), McGill University Health Centre, Montreal, Quebec, Canada.
16
Division of Cardiac Surgery (J.-F.M.), Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
17
Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research (J.A.), Jewish General Hospital, McGill University, Montreal, Quebec, Canada.

Abstract

BACKGROUND:

Older adults undergoing aortic valve replacement (AVR) are at risk for malnutrition. The association between preprocedural nutritional status and midterm mortality has yet to be determined.

METHODS:

The FRAILTY-AVR (Frailty in Aortic Valve Replacement) prospective multicenter cohort study was conducted between 2012 and 2017 in 14 centers in 3 countries. Patients ≥70 years of age who underwent transcatheter or surgical AVR were eligible. The Mini Nutritional Assessment-Short Form was assessed by trained observers preprocedure, with scores ≤7 of 14 considered malnourished and 8 to 11 of 14 considered at risk for malnutrition. The Short Performance Physical Battery was simultaneously assessed to measure physical frailty, with scores ≤5 of 12 considered severely frail and 6 to 8 of 12 considered mildly frail. The primary outcome was 1-year all-cause mortality, and the secondary outcome was 30-day composite mortality or major morbidity. Multivariable regression models were used to adjust for potential confounders.

RESULTS:

There were 1158 patients (727 transcatheter AVR and 431 surgical AVR), with 41.5% females, a mean age of 81.3 years, a mean body mass index of 27.5 kg/m2, and a mean Society of Thoracic Surgeons-Predicted Risk of Mortality of 5.1%. Overall, 8.7% of patients were classified as malnourished and 32.8% were at risk for malnutrition. Mini Nutritional Assessment-Short Form scores were modestly correlated with Short Performance Physical Battery scores (Spearman R=0.31, P<0.001). There were 126 deaths in the transcatheter AVR group (19.1 per 100 patient-years) and 30 deaths in the surgical AVR group (7.5 per 100 patient-years). Malnourished patients had a nearly 3-fold higher crude risk of 1-year mortality compared with those with normal nutritional status (28% versus 10%, P<0.001). After adjustment for frailty, Society of Thoracic Surgeons-Predicted Risk of Mortality, and procedure type, preprocedural nutritional status was a significant predictor of 1-year mortality (odds ratio, 1.08 per Mini Nutritional Assessment-Short Form point; 95% CI, 1.01-1.16) and of the 30-day composite safety end point (odds ratio, 1.06 per Mini Nutritional Assessment-Short Form point; 95% CI, 1.001-1.12).

CONCLUSIONS:

Preprocedural nutritional status is associated with mortality in older adults undergoing AVR. Clinical trials are needed to determine whether pre- and postprocedural nutritional interventions can improve clinical outcomes in these vulnerable patients.

KEYWORDS:

aortic valve replacement; malnutrition; mortality; older adults

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