Azrieli Heart Centre (M.G., L.G.R., J.A.), Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
Centre for Heart Valve Innovation, St Paul's Hospital, University of Vancouver, British Columbia, Canada (S.L., J.G.W.).
Circulation. 2018 Nov 13;138(20):2202-2211. doi: 10.1161/CIRCULATIONAHA.118.033887.
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.
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.
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/m, 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).
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.
接受主动脉瓣置换术（AVR）的老年患者存在营养不良的风险。术前营养状况与中期死亡率之间的关系尚未确定。
2012 年至 2017 年期间，在 3 个国家的 14 个中心进行了 FRAILTY-AVR（主动脉瓣置换术的脆弱性）前瞻性多中心队列研究。年龄≥70 岁、接受经导管或手术 AVR 的患者符合入选标准。术前由经过培训的观察者评估微型营养评估-简短表格，评分≤14 分的 7 分为营养不良，8 至 11 分的为存在营养不良风险。同时评估简短体能表现电池以测量身体虚弱程度，评分≤12 分的 5 分为严重虚弱，6 至 8 分为轻度虚弱。主要结局为 1 年全因死亡率，次要结局为 30 天复合死亡率或主要发病率。使用多变量回归模型调整潜在混杂因素。
共有 1158 例患者（727 例经导管 AVR 和 431 例手术 AVR），其中 41.5%为女性，平均年龄 81.3 岁，平均体重指数为 27.5kg/m2，胸外科医生协会预测死亡率为 5.1%。总体而言，8.7%的患者被归类为营养不良，32.8%存在营养不良风险。微型营养评估-简短表格评分与简短体能表现电池评分中度相关（Spearman R=0.31，P<0.001）。经导管 AVR 组有 126 例死亡（每 100 例患者年 19.1 例），手术 AVR 组有 30 例死亡（每 100 例患者年 7.5 例）。与营养状况正常的患者相比，营养不良患者的 1 年死亡率的粗风险几乎高出 3 倍（28%比 10%，P<0.001）。在校正脆弱性、胸外科医生协会预测死亡率和手术类型后，术前营养状况是 1 年死亡率的显著预测因素（优势比，每微型营养评估-简短表格点增加 1.08；95%置信区间，1.01-1.16）和 30 天复合安全终点（优势比，每微型营养评估-简短表格点增加 1.06；95%置信区间，1.001-1.12）。
术前营养状况与接受 AVR 的老年患者的死亡率相关。需要进行临床试验来确定术前和术后营养干预是否可以改善这些脆弱患者的临床结局。
