Transcatheter Aortic Valve Replacement in Functionally Dependent Patients

BACKGROUND: Evidence to guide treatment for functionally dependent elderly patients with severe aortic stenosis is limited, making clinical decisions challenging. OBJECTIVES: The aim of this study was to evaluate the safety and outcomes of transcatheter aortic valve replacement (TAVR) in functionally dependent elderly patients. Japan's government-mandated Long-Term Care Insurance (LTCI) grades were used as an objective measure of frailty and social dependency. METHODS: We retrospectively analyzed consecutive patients with verified LTCI data undergoing TAVR at a single high-volume center between 2019 and 2023. Outcomes included all-cause and cardiovascular mortality, heart failure rehospitalization, NYHA functional class, and the VARC-3 (Valve Academic Research Consortium-3) unfavorable outcome. RESULTS: A total of 649 patients with verified LTCI status were retrospectively analyzed. Of these, 101 (15.6%) and 179 (27.6%) were certified as requiring support and long-term care, respectively. Among the 3 groups, the long-term care group was older, more predominantly female, and exhibited higher levels of frailty, higher surgical risk, and more severe heart failure symptoms. Technical success exceeded 98% across all groups. Long-term care patients displayed a 2-fold higher risk of 2-year all-cause mortality (adjusted HR: 2.03; 95% CI: 1.35-3.09), whereas the support group had similar risk to the independent group (adjusted HR: 1.11; 95% CI: 0.62-1.98). Cardiovascular mortality and heart failure rehospitalization were similarly low across all strata. The VARC-3 unfavorable outcome occurred in 8.7%, 6.9%, and 14.0% of the independent, support, and long-term care groups, respectively (P = 0.096). CONCLUSIONS: TAVR was technically safe and potentially provided benefit even in care-dependent elderly patients. Functional dependence alone should not preclude referral for TAVR.