What is the risk of transcatheter aortic valve implantation (TAVI) in an 87‑year‑old patient with severe aortic stenosis, Montreal Cognitive Assessment (MoCA) score 18/30 (moderate cognitive impairment), moderate frailty, malnutrition, and a Timed Get‑Up‑and‑Go of 20 seconds?

Risk of TAVI in an 87-Year-Old with Cognitive Impairment, Frailty, and Malnutrition

This patient faces significantly elevated mortality risk after TAVI, with malnutrition and moderate frailty independently predicting 2-3 fold increased one-year mortality, though TAVI remains a reasonable option if severe symptomatic aortic stenosis is confirmed and life expectancy exceeds 1 year with potential for quality of life improvement. 1, 2, 3

Risk Stratification Based on Patient-Specific Factors

Malnutrition Impact

• Malnutrition independently increases all-cause mortality by 2.32-fold (95% CI: 1.50-3.60) after TAVI, making this the single most concerning modifiable risk factor in your patient 1
• Malnutrition affects 60-89% of TAVI patients depending on assessment tool, and is associated with older age, lower BMI, higher frailty, worse renal function, and anemia 1, 2
• The Geriatric Nutritional Risk Index (GNRI) <98 identifies patients at nutrition-related risk with hazard ratio of 1.44 (95% CI: 1.01-2.04) for mortality 2
• Acute Kidney Injury Network Stage 3 complications occur 6-fold more frequently in malnourished patients (3.6% vs 0.6%) 2

Frailty Impact

• Moderate frailty independently predicts increased one-year mortality with OR 1.42 (95% CI: 1.02-1.96) after AVR procedures 3
• Frailty and malnutrition share common endocrinological alterations including elevated cortisol and parathormone, with reduced IGF-1, testosterone, and DHEAS 3
• The combination of frailty and malnutrition creates synergistic risk beyond either factor alone 3

Cognitive Impairment Considerations

• MoCA score of 18/30 indicates moderate cognitive impairment, which raises critical questions about informed consent capacity, post-procedural rehabilitation potential, and quality of life improvement 4
• Guidelines emphasize that patients with comorbidities preventing quality of life improvement should be excluded from TAVI 5
• Life expectancy <1 year or moderate-to-severe dementia are relative contraindications to TAVI 4, 5

Functional Status Assessment

• Timed Get-Up-and-Go >20 seconds indicates significant functional impairment and poor rehabilitation potential, which compounds the risk profile 4
• This prolonged time suggests impaired mobility that may limit post-procedural recovery and independence 3

Procedural Risk Assessment Algorithm

Step 1: Confirm Severe Aortic Stenosis

• TAVI should only be performed for confirmed severe AS (valve area ≤1.0 cm², mean gradient ≥40 mmHg, or peak velocity ≥4.0 m/sec) 6, 7
• Use echocardiography with combined measurements of valve area and flow-dependent indices 7
• If low-flow, low-gradient suspected, perform dobutamine stress echocardiography to exclude pseudo-severe stenosis 7

Step 2: Evaluate Life Expectancy and Quality of Life Potential

• Patients with life expectancy <1 year should not receive TAVI 4, 5
• At 87 years with moderate frailty, malnutrition, cognitive impairment (MoCA 18/30), and poor functional status (Get-Up-and-Go >20 sec), carefully assess whether intervention will meaningfully improve quality of life 4
• The decision requires multidisciplinary Heart Team evaluation including cardiologists, cardiac surgeons, geriatricians, and anesthesiologists 4

Step 3: Calculate Surgical Risk Scores

• Use EuroSCORE II or STS-PROM to quantify surgical risk, though these scores have reduced predictive ability in very high-risk elderly patients 4
• At age 87 with multiple comorbidities, this patient likely has prohibitive surgical risk, making TAVI the only potential intervention option 4

Step 4: Assess Anatomical Feasibility

• Perform coronary angiography to exclude severe proximal coronary stenoses not amenable to PCI 7
• Measure aortic annulus (acceptable range 18-25 mm for balloon-expandable, 20-27 mm for self-expandable devices) 7
• Evaluate peripheral artery size, tortuosity, and calcification via angiography or CT 7
• Exclude bicuspid valve, asymmetric heavy calcification, and LV thrombus 7

Expected Outcomes in This High-Risk Patient

Mortality Risk

• Baseline 30-day mortality for standard TAVI is 5-18% 5
• With malnutrition, expect 2-3 fold increased mortality risk 1, 2
• One-year mortality in malnourished, frail patients approaches 30-40% based on combined risk factors 1, 2, 3

Complication Risk

• Procedural success rate remains 90-93.8% even in high-risk patients 5
• Vascular complications occur in 10-15% of cases 5
• Stroke risk is 3-9% 5
• AKI Stage 3 risk is significantly elevated (3.6%) in malnourished patients 2
• Paravalvular regurgitation occurs in 50% of cases, though severe regurgitation should be <5% 7

Functional Recovery

• Postoperative complications (major and minor) occur in approximately 50% of elderly patients with poor nutritional status 8
• 30-day functional capacity is reduced in urgent/high-risk TAVI patients, though survivors show improvement 9
• With Get-Up-and-Go >20 seconds and moderate frailty, rehabilitation potential is limited 3

Critical Decision Points

When TAVI May Be Reasonable

• If severe symptomatic AS is confirmed, symptoms are clearly attributable to valve disease, and estimated life expectancy exceeds 1 year with potential for meaningful quality of life improvement 4
• If patient and family understand the 30-40% one-year mortality risk and accept this in context of symptom relief 1, 2
• If anatomical assessment confirms feasibility without contraindications 7

When TAVI Should Be Avoided

• If cognitive impairment (MoCA 18/30) prevents meaningful informed consent or suggests dementia severity that precludes quality of life benefit 4, 5
• If life expectancy is estimated <1 year based on combined comorbidities 4, 5
• If malnutrition and frailty are so severe that rehabilitation is futile 3, 8
• If unintentional weight loss >2.8% in preceding 6 months, which predicts first-year mortality 8

Common Pitfalls to Avoid

• Do not proceed with TAVI based solely on age and surgical risk scores without comprehensive geriatric assessment including cognitive function, frailty, nutrition, and rehabilitation potential 4
• Do not underestimate the mortality impact of malnutrition—it rivals or exceeds traditional cardiac risk factors 1, 2
• Do not assume all 87-year-olds are the same—functional status and cognitive function vary dramatically and determine outcomes 3, 8
• Consider pre-procedural nutritional optimization if time permits, though evidence for this strategy improving TAVI outcomes is limited 1, 2
• Ensure intensive care monitoring for at least 24 hours post-procedure given elevated complication risk 5