Manolis Antonis S, Manolis Antonis A
Third Department of Cardiology, Athens University School of Medicine, Athens, Greece.
Ann Cardiothorac Surg. 2017 Sep;6(5):524-531. doi: 10.21037/acs.2017.07.11.
A growing number of nonagenarians is recorded as life expectancy increases. Unfortunately, this extreme-aged group is plagued by increased prevalence of aortic stenosis amidst a higher occurrence of comorbidities that pose dilemmas to cardiologists and cardiac surgeons when having to choose a conservative or interventional treatment modality, and a surgical or transcatheter aortic valve implantation (TAVI) approach. TAVI is an expensive procedure, which also confers a higher mortality and morbidity risk in nonagenarians, compared to younger patients. Considering the physiologic rather the chronologic age alone, and adopting a shared-decision making approach (participatory medicine), it may be more realistic to determine a patient's candidacy for this non-surgical therapeutic modality. Thus, it comes down to the patient selection process by having the heart team review each nonagenarian case individually and getting the patient and the family involved, always aiming to prolong and improve patient's quality of life (QoL), but also taking into consideration patient preferences and values, sharing and respecting goals, realistic expectations, and end-of-life views and ideas. One should keep in mind that there is always the possibility that TAVI may be clinically futile for patients who have a multitude of comorbidities and extreme frailty, for whom a transition to palliative care might be prudent. Selecting nonagenarian patients with low comorbidity index and with no extreme frailty, adopting a minimalistic approach and paying attention to vascular access hemostasis may provide the elements that may lead to a successful, desirable and hopefully cost-effective outcome.
随着预期寿命的增加，记录在案的九旬老人数量不断增长。不幸的是，这一高龄群体主动脉瓣狭窄的患病率增加，同时合并症发生率更高，这给心脏病专家和心脏外科医生在选择保守或介入治疗方式以及手术或经导管主动脉瓣植入术（TAVI）方法时带来了两难困境。TAVI是一种昂贵的手术，与年轻患者相比，九旬老人接受该手术的死亡率和发病率风险也更高。仅考虑生理年龄而非实际年龄，并采用共同决策方法（参与式医疗），确定患者是否适合这种非手术治疗方式可能更现实。因此，这归结为心脏团队对每个九旬老人病例进行单独评估的患者选择过程，并让患者及其家属参与进来，始终旨在延长和改善患者的生活质量（QoL），同时也要考虑患者的偏好和价值观，分享并尊重目标、现实期望以及临终观点和想法。应牢记，对于有多种合并症且极度虚弱的患者，TAVI在临床上可能毫无效果，对于这类患者，转向姑息治疗可能是审慎之举。选择合并症指数低且无极度虚弱的九旬老人患者，采用简约方法并关注血管通路止血，可能会带来成功、理想且有望具有成本效益的结果。
