Osteosarcopenia in older adults undergoing transcatheter aortic valve replacement: A narrative review of mortality and frailty implications

Table 1 Characteristics of key studies on frailty and osteosarcopenia in transcatheter aortic valve replacement patients

Ref.	Year	Study type	Key inclusion/exclusion criteria	Patient’s characteristics	Assessment method	Key findings
Green et al[23]	2012	Single-center prospective study	Inclusion: Age ≥ 60 years, severe calcific AS, with advanced cardiac symptoms, TAVR candidates. Exclusion: Inoperability	159 patients, mean age 86 years, 50% male	Frailty score derived from gait speed, grip strength, serum albumin, and ADL	Frailty was associated with a 35-fold increase in 1-year mortality but not with procedural complications
Green et al[24]	2015	Post hoc analysis	Inclusion: Age ≥ 60 years, severe symptomatic AS requiring TAVR, frailty assessed at 3 high-enrolling sites. Exclusion: Missing baseline frailty assessment	244 patients, mean age 86 years, 51.6% male	Frailty assessed using serum albumin, grip strength, gait speed, and Katz ADL survey	Frail individuals had higher 1-year mortality (32.7% vs 15.9% nonfrail) and poor outcomes (50% vs 31.5%)
Afilalo et al[4]	2017	Prospective multicenter cohort study	Inclusion: Age ≥ 70, severe AS, TAVR/surgical aortic valve replacement planned. Exclusion: Dementia, metastatic cancer, acute myocardial infarction < 30 days	1020 patients, mean age 82 years, 59% male	Fried, Fried+, Rockwood, and EFT etc.	EFT strongly predicted 1-year mortality (aOR = 3.72; 95%CI: 2.54-5.45), 1-year disability (aOR = 2.13; 95%CI: 1.57-2.87), and death at 30 days (aOR = 3.29; 95%CI: 1.73-6.26)
Kundi et al[25]	2019	CMS MedPAR database	Inclusion: Age ≥ 70 years, referred for TAVI (2011-2015), severe symptomatic AS. Exclusion: Declined consent	28531patients, mean age 815 years, 53.6% male	Hospital Frailty Risk Score	1-year mortality rates were 76% in low-risk patients, 17.6% in intermediate-risk patients, and 30.1% in high-risk patients (log rank P < 0.001)
Skaar et al[26]	2019	Prospective observational study	Inclusion: Age ≥ 65 years, undergoing transcatheter mitral valve repair/TAVR. Exclusion: Age < 65 years	142 patients, 54% women, mean age 83 years	A novel geriatric assessment frailty score	Geriatric assessment frailty score predicted mortality within 2 years, with an estimated HR of 1.79 (95%CI: 1.34–2.36, P < 0.001)
Goudzwaard et al[27]	2020	Prospective, observational study	Inclusion: Severe symptomatic AS patients referred for TAVI	239 patients, mean age 808 years, 49.8% male	Erasmus Frailty Score	Frailty was an independent predictor of deteriorated HR quality of life 1 year after TAVI (OR = 2.24, 95%CI: 1.07–4.70, P = 0.003)
Seoudy et al[28]	2021	Retrospective cohort study	Inclusion: Symptomatic AS, underwent transfemoral TAVR, Geriatric Nutritional Risk Index	1930 patients, mean age 82 years, 52.5% female	GNRI	After a mean follow-up of 21.1 months, all-cause mortality was significantly increased in the low-GNRI group compared with the normal-GNRI group (P < 0.001)
Arnold et al[29]	2022	PARTNER 2A trial, SAPIEN 3 intermediate-risk registry, and PARTNER 3 trial	Inclusion: Intermediate-surgical-risk or low-surgical-risk patients, Severe symptomatic AS, Enrolled in PARTNER 2A trial, SAPIEN 3 intermediate-risk registry, or PARTNER 3 trial	3025 patients, mean age 793 years, 61.6% men	Frailty was examined as a continuous variable based on grip strength, gait speed, albumin, and ADL	Increasing frailty (none vs prefrail vs frail) was associated with higher 2-year mortality (5.5% vs 11.1% vs 22.8%; log-rank P < 0.001) and worse 2-year health status among survivors (Kansas City Cardiomyopathy Questionnaire scores adjusted for baseline: 84.8 vs 79.6 vs 77.4, P < 0.001)
Strange et al[30]	2023	Danish nationwide registries study	Inclusion: Undergoing first-time TAVR, Valid Hospital Frailty Risk Score	5971 patients, median age 81 years, and 55.4% men	Hospital Frailty Risk Score	1-year risk of death was 5.8% of patients in the low frailty group compared with 10.3% of patients in the intermediate frailty group and 15.6% of patients in the high frailty group
Stein et al[31]	2024	Multicenter prospective registry	Inclusion: Pre-TAVR CT available. Exclusion: Prior valve surgery, end-stage renal disease	445 patients, median age 829 years, 41% female	3-part definition psoas muscle area indexed to height; handgrip strength; and gait speed	Among the 3 components of sarcopenia, only slower gait speed (muscle performance) was independently associated with increased post-TAVR mortality (aHR = 1.38 per 1 SD decrease (95%CI: 1.11–1.72); P = 0.004)
Persits et al[32]	2024	Retrospective cohort study	Inclusion: aged ≥ 70 years, undergoing TAVR, Pre-TAVR CT scans available. Exclusion: Emergent TAVR procedures, unstable vital signs, CT scans with fields of view excluding the abdomen	184 patients, average age 806 years, 41.8% female	Sarcopenia was defined as having both low muscle mass and either muscle weakness or poor physical performance. Frailty status was assessed using Green score	There were higher rates of the postoperative adverse events in patients with sarcopenia (54.8%) and frailty (41.9% with the Adapted Green and 50.5% with the Green-SMI score) compared to their nonsarcopenic (30.3%) and nonfrail counterparts (25.4% with the Adapted Green and 18.8% with the Green-SMI score)
Petrovic et al[33]	2024	Prospective multicentre WIN-TAVI registry	Inclusion: Women, with symptomatic severe AS, Intermediate or high surgical risk, pre-TAVR Fried frailty criteria assessment. Exclusion: Missing frailty assessment data	1019 women, mean age 82 years	Fried frailty criteria	1-year risk of the primary outcome was significantly higher in prefrail and frail (20.2%) than in nonfrail (14.9%) women (aHR = 1.51). The risk of major bleeding was higher in prefrail or frail (19.9%) than in nonfrail (10.0%) women (aHR = 2.06)
Solla-Suarez et al[7]	2024	Prospective multicenter cohort study	Inclusion: Undergoing TAVR, pre-TAVR CT scans available, Availability of HGS or gait speed measurements. Exclusion: Incomplete CT imaging, missing HGS or gait speed data	605 patients, mean age 826 years, 45% female	Osteosarcopenia was defined as a combination of low PMA and low VBD	One-year mortality was highest in osteosarcopenia (32%) followed by low PMA alone (14%), low VBD alone (11%), and normal bone and muscle status (9%) (P < 0.001)

ADL: Activity of daily living; AHR: Adjusted hazard ratio; AOR: Adjusted odds ratio; AS: Aortic stenosis; CT: Computed tomography; EFT: Essential Frailty Toolset; GNRI: Geriatric Nutritional Risk Index; HGS: Handgrip strength; HR: Hazard ratio; PMA: Psoas muscle area; TAVI: Transcatheter aortic valve implantation; TAVR: Transcatheter aortic valve replacement; SMI: Skeletal muscle mass index; VBD: Vertebral bone density.