title: Determinants in treatment decision-making in older patients with symptomatic severe aortic stenosis.
abstract: BACKGROUND
  Three treatment options are available for patients with aortic stenosis: surgical aortic valve replacement (SAVR), transcatheter aortic valve implantation (TAVI) and medical treatment (MT). However, little is known about how Heart Team treatment decisions are made under routine conditions. The aim of this study was to identify the cardiac and geriatric components associated with treatment decision-making in older patients with symptomatic severe aortic stenosis.
  
  
  METHODS
  Between 2011 and 2013, 337 consecutive patients ≥75 years old referred for pre-operative evaluation in Nantes University Hospital had a comprehensive cardiac and geriatric assessment. In this observational retrospective study, relationships between treatment decision-making and cardiac or geriatric components were evaluated through multivariable models.
  
  
  RESULTS
  Surgical aortic valve replacement was proposed to 108 patients, TAVI to 131 and medical treatment to 98 patients. Mean age was 83±4 years and 51% were women. Geriatric components associated with treatment decision-making between SAVR vs. TAVI were age (p<0.001, OR=0.790), comorbidity score (p=0.027, OR=0.86), functional status (p<0.001, OR=1.46), and gait speed (p<0.001, OR=0.23). Cardiac components associated with decision-making between SAVR vs. TAVI were history of previous cardiac surgery (p<0.001, OR=0.09), left ventricular ejection fraction <50% (p<0.001, OR=0.14), coronary artery disease requiring revascularization (p=0.019, OR=0.4). Between TAVI vs. medical treatment, only history of previous cardiac surgery and presence of another severe valve disease were significant.
  
  
  CONCLUSIONS
  Comorbidities, functional status and physical performance, were significantly associated with the consensual treatment decision-making, independently of cardiac components in older patients with symptomatic severe aortic stenosis.
authors.affiliation: Department of Geriatrics, EA 1156-12, Nantes University Hospital, Nantes, France. Electronic address: anne-sophie.boureau@etu.univ-nantes.fr.
authors.forename: A S
authors.initials: AS
authors.lastname: Boureau
authors.affiliation: Inserm, UMR 1087, Department of Cardiology and Vascular Diseases, Institut du Thorax, Nantes University Hospital, Nantes, France.
authors.forename: J N
authors.initials: JN
authors.lastname: Trochu
authors.affiliation: Department of Geriatrics, EA 1156-12, Nantes University Hospital, Nantes, France.
authors.forename: C
authors.initials: C
authors.lastname: Colliard
authors.affiliation: Department of Statistics, Nantes University Hospital, Nantes, France.
authors.forename: C
authors.initials: C
authors.lastname: Volteau
authors.affiliation: Inserm, UMR 1087, Department of Cardiology and Vascular Diseases, Institut du Thorax, Nantes University Hospital, Nantes, France.
authors.forename: P
authors.initials: P
authors.lastname: Jaafar
authors.affiliation: Inserm, UMR 1087, Department of Cardiology and Vascular Diseases, Institut du Thorax, Nantes University Hospital, Nantes, France.
authors.forename: T
authors.initials: T
authors.lastname: Manigold
authors.affiliation: Inserm, UMR 1087, Department of Cardiology and Vascular Diseases, Institut du Thorax, Nantes University Hospital, Nantes, France.
authors.forename: T
authors.initials: T
authors.lastname: Le Tourneau
authors.affiliation: Department of Geriatrics, EA 1156-12, Nantes University Hospital, Nantes, France.
authors.forename: G
authors.initials: G
authors.lastname: Berrut
authors.affiliation: Department of Geriatrics, EA 1156-12, Nantes University Hospital, Nantes, France.
authors.forename: L
authors.initials: L
authors.lastname: de Decker
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D006328:Cardiac Catheterization; D000066491:Clinical Decision-Making; D015897:Comorbidity; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
keywords: Aortic stenosis; Decision-making; Older patients; Treatment