Futility, Benefit, and Transcatheter Aortic Valve Replacement
Open accessAbstract
Transcatheter aortic valve replacement (TAVR) is a transformative innovation that provides treatment for high or prohibitive surgical risk patients with symptomatic severe aortic stenosis who either were previously not referred for or were denied operative intervention. Trials have demonstrated improvements in survival and symptoms after TAVR versus medical therapy; however, there remains a sizable group of patients who die or lack improvement in quality of life soon after TAVR. This raises important questions about the need to identify and acknowledge the possibility of futility in some patients considered for TAVR. In this very elderly population, a number of factors in addition to traditional risk stratification need to be considered including multimorbidity, disability, frailty, and cognition in order to assess the anticipated benefit of TAVR. Consideration by a multidisciplinary heart valve team with broad areas of expertise is critical for assessing likely benefit from TAVR. Moreover, these complicated decisions should take place with clear communication around desired health outcomes on behalf of the patient and provider. The decision that treatment with TAVR is futile should include alternative plans to optimize the patient's health state or, in some cases, discussions related to end-of-life care. We review issues to be considered when making and communicating these difficult decisions.
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Because patients who develop severe aortic stenosis are usually older adults, their symptoms may also result in part from normal aging, numerous comorbidities or frailty.
“However, because patients who develop severe AS are usually older adults, these symptoms may also result, in part, from normal aging, numerous comorbidities or frailty202.”
From Calcific aortic stenosis (2016) · cites this paper as [202]
The Introduction’s “Anticipated Benefit of TAVR” section distinguishes patients whose main medical problem can be ascribed to severe AS, and “Geriatric Risk Stratification” describes comorbidities and frailty as prevalent in TAVR patients. These passages support the possibility that problems other than AS contribute to patients’ condition, but they do not specifically attribute the symptoms to normal aging or establish that frailty causes those symptoms. (LLM, conf=0.80)
Experimental — accuracy not yet measuredGiven the high prevalence of frailty and disability in this patient population, the relationship between valvular stenosis and overall quality of life is complex and variable.
“Given the high prevalence of frailty and disability in this patient population, the relationship between valvular stenosis and overall quality of life is also complex and variable.202”
From Calcific aortic stenosis (2016) · cites this paper as [202]
Experimental — accuracy not yet measuredIn general, TAVR is associated with a survival advantage compared with conservative management without aortic valve replacement.
“Although, in general, TAVR is associated with a survival advantage compared to conservative (no AVR) management”
From Calcific aortic stenosis (2016) · cites this paper as [202]
Aortic valve replacement is indicated in patients with severe symptomatic aortic stenosis both to increase life expectancy and to improve symptoms and quality of life.
“AVR is indicated in patients with severe symptomatic AS both to increase life expectancy and improve symptoms and quality of life3;4;199;202;252;253.”
From Calcific aortic stenosis (2016) · cites this paper as [202]
A sizable subgroup dies soon after TAVR or does not experience improved quality of life, suggesting potential futility of TAVR in some patients.
“there is a sizable sub-group that dies soon after TAVR or does not experience an improvement in quality of life, suggesting potential futility of TAVR in some patients201;202;220;244;245.”
From Calcific aortic stenosis (2016) · cites this paper as [202]
When uncertainty exists whether a patient will benefit clinically from valve replacement because of markedly depressed LV function or concomitant oxygen-dependent lung disease or other factors, balloon aortic valvuloplasty may have diagnostic utility.
“When there is uncertainty whether a patient will benefit clinically from valve replacement owing to markedly depressed LV function or concomitant oxygen dependent lung disease or other factors, a BAV may have diagnostic utility to determine whether valve replacement is appropriate202.”
From Calcific aortic stenosis (2016) · cites this paper as [202]
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- Authors
- Lindman, B. R., Alexander, K. P., O'Gara, P. T., & Afilalo, J.
- Affiliations
- Washington University in St. Louis (US)
- Duke University (US)
- Jewish General Hospital (CA)
- Corresponding author
- Lindman, Brian R.
- Venue
- JACC: Cardiovascular Interventions
- Publisher
- Elsevier BV
- Published
- 2014-07
- Volume
- 7
- Issue
- 7
- Pages
- 707-716
- ISSN
- 1876-7605 (ISSN-L)
- 1936-8798
- PMC
- PMC4322002
- OpenAlex
- W1973241413
- Cited by
- 222
- References
- 70
- Citations by year
- 2026: 7 · 2025: 19 · 2024: 8 · 2023: 10 · 2022: 18 · 2021: 20 · 2020: 23 · 2019: 17 · 2018: 23 · 2017: 22 · 2016: 25 · 2015: 23 · 2014: 6
- FWCI
- 4.08
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- JACC: Cardiovascular Interventions (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Washington University Institute of Clinical and Translational Sciences (#UL1 TR000448, #KL2 TR000450)
- BG Medicine
- Roche Diagnostics
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Valve Diseases and Treatments
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Aortic Disease and Treatment Approaches
- Keywords
- transcatheter aortic valve implantation, aortic stenosis, futility of treatment, anticipated benefits, very elderly patients, multimorbidity, frailty, cognitive impairment, disability, risk stratification, end-of-life care, shared decision-making, quality of life
- MeSH terms
- Age Factors, Aged, Aged, 80 and over, Aortic Valve, Aortic Valve Stenosis, Decision Support Techniques, Cardiac Catheterization, Heart Valve Prosthesis, Hemodynamics, Humans, Middle Aged, Prosthesis Design, Risk Factors, Severity of Illness Index, Geriatric Assessment, Comorbidity, Frail Elderly, Treatment Outcome, Medical Futility, Risk Assessment, Patient Selection, Heart Valve Prosthesis Implantation, Patient Preference
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