With the ageing population the demand for cardiac operations in elderly patients has steadily increased over the last 10 to 15 years. Moderate-to-severe AS occurs in 5% of individuals 75 to 86 years of age, and critical AS is seen in >5% of those >85 years of age
. In-hospital death and stroke rates may be as high as 8.5% and 8%, respectively
. Mean duration of postoperative hospital stay in most reports is >2 weeks for very elderly patients, with most being discharged to nursing care facilitates.
Today, about one third of patients with severe AS are not referred for valve replacement surgery because of the risk perceived by both patients and physicians. TAVI is a robust technique, which offers advantages to high surgical risk patients
[5–7]. Elderly with AS often present comorbidities, which are responsible for the considerable heterogeneity of operative risk and which hamper the decision, if the beneficial outcome of surgery, compared with spontaneous outcome, outweighs the risk of intervention. However there are no explicit age related restrictions for surgical aortic valve replacement according to guidelines on treatment of severe symptomatic AS
[1, 11]. In nonagenarians, age alone accounts for a predicted logistic EuroSCORE mortality risk of 6.55% for male patients, as for females it raises to 8.89% without any other preoperative risk factors
. In our series predicted logistic EuroSCORE mortality rate was 32.0 ± 9.5% for whole cohort. Feasibility of TAVI on nonagenarians was proven by the high procedural success rate (100%). The reduction in afterload after TAVI resulted in immediate marked hemodynamic improvement and translated into symptomatic relief, with a reduction in NYHA class by a mean of 1.8 grades. We also show markedly improvements in the AVA from 0.6 to 1.8 cm2 and reductions in mean pressure gradients from 60.2 to 8.3 mmHg, which compare favorably to the results for younger patients treated with TAVI
[5, 6, 12, 13].
Safety was assessed using primary and secondary endpoints following recommendations of the Valve Academic Research Consortium
. As there is no trial exclusively in nonagenarians or subgroup analyses of large trials our outcomes are not comparable with the literature.
All-cause mortality is considered as the “gold standard” in surgical clinical trials with cardiovascular mortality as an important secondary endpoint
[4, 9, 14]. In our study the 30-day follow up all cause and cardiovascular mortality was 27.3% and 9.1%, respectively, which is slightly higher or comparable to 11.4% to 29% all cause mortality for nonagenarians with low comorbidity index as stated by the estimated logistic EuroSCORE treated with surgical aortic valve replacement
[15–18] and 5% to 20% all-cause and 10% cardiovascular mortality for TAVI performed at younger patients
Like mortality, operative morbidity in the elderly is higher than in younger patients. This is true in particular for the frequency of stroke. Some authors have shown that older age is strongly related to a neurological event, the latter being associated with a previous history of stroke and advanced atherosclerotic disease
. We report one major stroke (9.1%) in our cohort, which compares to 2.1% to 8.9% in a nonagenarian population treated with surgical aortic valve replacement
[5–7] and 0% to 10% for TAVI performed at younger patients
[5–7, 13]. Our periprocedural (<72h) (9.1%), and spontaneous (9.1%) myocardial infarction rate is markedly higher compared to 0% to 0.3% for TAVI performed at younger patients
[5–7, 13] and 5.7% for surgical valve replacement performed at nonagenarians
 pointing out the high cardiovascular risk profile of our severely ill patients. Two life-threatening or disabling bleeding occurred (18.2%) which compares favorably to rates of 3.6% to 24% for TAVI performed at younger patients
[5–7, 13]. Vascular complications after TAVI occur with an incidence of 7.5% to 16.3% and remain a significant cause of mortality and morbidity
[5–7, 13]. We report similar rates of major and minor vascular complications. 3 patients presented acute kidney injury grade I (27.3%), and one patient grad III (9.1%), which is comparable to 6% to 28% of acute kidney injuries reported in the literature
As shown in previous studies, the very elderly are more likely to experience postoperative complications, and consequently, a prolonged hospitalization and intensive therapy
[21, 22]. However, the length of hospital and ICU stay reported in our study (18.5 ± 5.4 and 3.36 ± 1.9 days respectively) is comparable to data for younger patients (7 to 17 days and 2.8 days respectively
In general population, life expectancy in nonagenarians is 2.5 and 3.5 years for men and women, respectively
. Although one should take into account the very advanced age and frailty of these subjects in the interpretation of such results, all-cause death is still not low despite successful TAVI. However, the patients who survived the follow-up achieved in most cases an improvement in their clinical symptoms. Thus, TAVI in the very elderly have the potential to significantly ameliorate functional status and quality of life, at the price of considerable periinterventional and follow-up mortality rates. The risk-benefit balance of TAVI of nonagenarians should then be considered to be paradigmatically different than in the younger candidates, in whom the prolongation of life is usually considered the primary aim. The clinician should consider these findings while evaluating the very elderly for TAVI and properly discuss these issues in the light of the patient’s expectations.