PhD defence J.A. (Jeanette) Goudzwaard

Summary:

The number of older patients that are in need for surgical intervention in continuously increasing. Older age and frailty are both risk factors for unwanted outcomes after surgery. Previously, patients who were considered too old or frail were denied surgery because of the high risks of unwanted outcomes after surgery.

Frailty is considered a complex, multidimensional syndrome which eventually leads to decreased resilience and therefore making patients more vulnerable to stressors. Recent studies show that indifferent from the nature of surgery, e.g either being high-risk surgery or low-risk ambulant surgery, frailty remains an independent predictor of mortality.

In cardiac surgery, frailty has become a relevant topic, since the average age and the complexity of patients have increased. Treatment options for cardiac diseases have diversified, from medical management, to minimal invasive procedures to cardiac surgery.

Aortic stenosis (AoS) is the most common valvular heart disease in aging persons. When aortic valve stenosis becomes symptomatic, the prognosis is dismal with high mortality rates up to 75% in three years if the disease is not treated. Replacement of the aortic valve reduces symptoms and improves survival in patients with severe aortic stenosis. Until 2002, surgical replacement of the aortic valve (SAVR) was the only option to treat severe aortic valve stenosis, but at least 30% of patients with severe symptomatic aortic stenosis could not undergo
surgery due to high or unacceptable surgical risk due to advanced age or extensive comorbidity. In 2002 a new procedure was developed: Transcatheter Aortic Valve Implantation (TAVI). In this procedure a bioprosthetic valve is inserted through a catheter and implanted within the diseased native aortic valve.

Transcatheter Aortic Valve Implantation is increasingly being used as a treatment option for patients with severe aortic stenosis with high or unacceptable surgical risk due to age, existing comorbidity or frailty. With TAVI, this group of patients who previously could not be treated, becomes eligible for treatment, but since this is a whole new category of patients, this eligibility also comes with challenges.

The overall aim of this thesis was to better understand the implications of several aspects of age related conditions and processes in TAVI candidates and optimizing care by incorporating frailty in clinical decision making and to improve periprocedural care.