Letter to the Editor: Transcatheter aortic valve implantation beyond 85 years: Age is no longer the limiting factor, but risk stratification still matters

Abstract

The rapid expansion of transcatheter aortic valve implantation (TAVI) has fundamentally reshaped the management of severe aortic stenosis in elderly and high-risk populations. However, evidence specifically addressing outcomes in the very elderly, particularly patients aged 85 years and older, needs further exploration. In this context, the retrospective cohort study by Algethami et al provides interesting and clinically relevant insights into mid-term survival following TAVI in this advanced-age group. The authors report favorable survival rates at 1 year and 3 years, reinforcing the concept that chronological age alone should not constitute a contraindication to TAVI. Importantly, their findings highlight obesity as a significant predictor of early mortality, underscoring the need for refined risk stratification beyond conventional age-based decision-making. This article discusses the implications of these results within the evolving landscape of structural heart disease management, emphasizing the shift from age-centered to biology- and comorbidity-driven patient selection. Furthermore, it explores how factors such as frailty, metabolic burden and non-cardiac comorbidities should increasingly inform multidisciplinary heart team decisions. As TAVI continues to expand into older populations, studies such as this one help define realistic expectations, guide individualized care and support evidence-based expansion of indications in the very elderly.

Key Words: Transcatheter aortic valve implantation; Aortic stenosis; Elderly patients; Transcatheter aortic valve implantation; Risk stratification; Frailty; Survival outcomes

Core Tip: As transcatheter aortic valve implantation expands into younger populations, chronological age alone is no longer an appropriate barrier to intervention. The study by Algethami et al demonstrates favorable mid-term survival in patients aged 85 years and older, reinforcing the safety and feasibility of transcatheter aortic valve implantation in carefully selected individuals. Importantly, the identification of obesity as a predictor of early mortality highlights the limitations of age-based risk scores and underscores the need for biology- and comorbidity-driven patient selection within multidisciplinary heart teams.

TO THE EDITOR

Transcatheter aortic valve implantation (TAVI) has become the established therapy for severe aortic stenosis, particularly in patients who are not suitable candidates for surgical aortic valve replacement (SAVR)[1]. Overall, TAVI is associated with favorable outcomes in terms of mortality, morbidity, and quality of life, and it commonly offers practical advantages such as fewer perioperative complications and shorter hospitalization compared with surgery[2,3]. In routine practice, clinicians must choose between TAVI and SAVR, and patient age remains a major driver of this decision. Widely used risk models, including the Society of Thoracic Surgeons score and the European System for Cardiac Operative Risk (EuroSCORE), incorporate age as a key component of operative risk estimation[3-5]. However, robust evidence in very old adults is limited. For example, the EuroSCORE development cohort included only a small number of nonagenarians. Beyond formal risk scoring, age alone often strongly influences treatment selection. Reflecting this, current guideline frameworks generally favor TAVI over SAVR in older patients, such as those above 80 years or with limited life expectancy in American guidance, and those above 75 years in European guidance[2,3].

Several major studies have reported that TAVI is not inferior to SAVR in older or higher-risk populations. These include trials showing comparable 1-year all-cause mortality in older adults treated with either strategy, subgroup analyses indicating noninferiority among patients older than 85 years in high-risk cohorts, and longer-term follow-up demonstrating noninferior survival out to 5 years[4-8]. Despite these encouraging data, dedicated research with meaningful follow-up specifically in patients older than 85 years remains scarce, in elective or urgent procedures[9,10]. In this context, the retrospective cohort study by Algethami et al[1] provides interesting and clinically relevant insights into mid-term survival outcomes after TAVI in patients of very advanced age.

REASSESSING CHRONOLOGICAL AGE IN TAVI DECISION-MAKING

One of the central messages emerging from this study is that chronological age alone should no longer be viewed as a prohibitive factor for TAVI. The reported 1-year and 3-year survival rates of 82% and 63%, respectively, in a cohort with a mean age approaching 90 years are noteworthy and broadly consistent with outcomes observed in younger high-risk populations from landmark trials and registries[1]. These findings reinforce the paradigm shift already reflected in contemporary guidelines, which increasingly prioritize life expectancy, functional status and procedural risk over age thresholds alone. Importantly, the data from Algethami et al[1] extend this concept into the “oldest old”, a group frequently excluded from randomized evidence. Their experience supports the notion that, when carefully selected by a multidisciplinary heart team, very elderly patients can derive meaningful survival benefit from TAVI, with acceptable mid-term outcomes and sustained hemodynamic improvement.

OBESITY AND THE LIMITS OF CONVENTIONAL RISK SCORES

Perhaps the most provocative finding of the study is the identification of obesity (body mass index ≥ 30 kg/m²) as an independent predictor of early mortality. This observation challenges the often-cited “obesity paradox” described in cardiovascular disease and highlights the complex interplay between metabolic burden, frailty, and procedural resilience in advanced age[1]. In very elderly patients, obesity may reflect sarcopenic obesity, reduced mobility, chronic inflammation, or impaired cardiopulmonary reserve, factors that are not adequately captured by traditional surgical risk models. From a practical procedural perspective, obesity may complicate TAVI in very elderly patients through several mechanisms. Increased body habitus can make transfemoral vascular access more challenging because of deeper femoral vessels, more difficult anatomical landmark identification and potentially greater reliance on ultrasound- or imaging-guided puncture. Obesity may also complicate vascular closure and hemostasis, thereby increasing concern for access-site bleeding or vascular complications. In the post-procedural period, impaired respiratory mechanics, obstructive sleep apnea, reduced mobility and delayed rehabilitation may further limit recovery. Importantly, these mechanisms were not specifically evaluated in the study by Algethami et al[1]. Therefore, they should be interpreted as plausible clinical explanations requiring confirmation in larger prospective cohorts.

Current risk stratification tools, including the Society of Thoracic Surgeons score and the EuroSCORE, were not designed for octogenarians and nonagenarians and rely heavily on age as a surrogate for biological vulnerability[11]. The findings from this study underscore the limitations of age-weighted scores and emphasize the need for more nuanced assessment frameworks that incorporate body composition, frailty indices, nutritional status and non-cardiac comorbidities.

MOVING FROM AGE-BASED TO BIOLOGY-BASED SELECTION

Beyond obesity, the associations observed with pulmonary hypertension and carotid artery disease, albeit limited by small event numbers, further illustrate the importance of global cardiovascular and extracardiac disease burden in shaping outcomes after TAVI. In patients aged 85 years and older, procedural success alone does not guarantee favorable survival; outcomes are determined by the patient’s overall biological reserve and competing risks of mortality. This reinforces the evolving role of the heart team, which must move beyond binary assessments of operability toward individualized decision-making grounded in geriatric principles. Comprehensive geriatric assessment, evaluation of frailty and cognitive function, and realistic discussions regarding goals of care are particularly critical in this age group.

In routine practice, this assessment may be supported by validated and pragmatic tools such as the Clinical Frailty Scale, which provides a rapid global estimate of frailty, and the Essential Frailty Toolset, which incorporates lower-extremity strength, cognitive function, hemoglobin level and serum albumin. These tools may help heart teams move beyond chronological age and better identify very elderly patients who are likely to achieve meaningful survival, functional recovery and quality-of-life benefit after TAVI. Studies such as the present one help refine expectations and support informed, patient-centered choices.

IMPLICATIONS FOR PRACTICE AND FUTURE RESEARCH

While limited by its retrospective, single-center design and modest sample size, the study by Algethami et al[1] contributes valuable real-world data to a sparsely studied population. Importantly, the study by Algethami et al[1] was a single-arm observational analysis of patients who underwent TAVI and did not include a comparator group treated with SAVR or conservative medical therapy. Therefore, the reported 1-year and 3-year survival rates of 82% and 63%, respectively, should be interpreted as descriptive post-TAVI outcomes in a carefully selected very elderly cohort rather than as comparative effectiveness data. It highlights both the feasibility and the boundaries of TAVI in very elderly patients, reminding clinicians that expanding indications must be accompanied by refined patient selection. Future studies should aim to validate these findings in larger, multicenter cohorts and explore the mechanistic links between obesity, frailty and post-TAVI outcomes in advanced age. Incorporation of standardized frailty metrics and longitudinal quality-of-life assessments will be essential to complement survival data and better define the true benefit of intervention in this population.

CONCLUSIONS

The experience reported by Algethami et al[1] adds to a growing body of evidence demonstrating that meticulous patient selection in very elderly individuals is essential to optimize clinical outcomes after TAVI. However, the study also serves as an important reminder that as indications expand, risk stratification must evolve. In the very elderly, biology, comorbidity burden and functional reserve, not chronological age, should guide therapeutic decisions. As structural heart interventions continue to mature, embracing this nuanced approach will be key to delivering value-based, patient-centered care in an aging society.