Transcatheter Aortic Valve Replacement in Functionally Dependent Patients

Figures

• 

  Figure 1. Levels of Support and Care in the Japanese Long-Term Care Insurance System Classification of individuals into non-certified (independent), support level (1-2), and long-term care level (1-5) categories, determined by a standardized national assessment of physical, cognitive, and daily living function.

• 

  Central Illustration. Long-Term Care Status and TAVR Outcomes Patients undergoing transcatheter aortic valve replacement (TAVR) were stratified according to Japan’s Long-Term Care Insurance (LTCI) certification as noncertified, requiring support (ie, Yo-Shien), or requiring long-term care (ie, Yo-Kaigo), reflecting increasing functional dependence. The illustration summarizes functional profiles across Long-Term Care Insurance categories and their association with outcomes. VARC-3 unfavorable outcome, a proxy for treatment futility, was numerically higher with greater care dependency but was not statistically different. All-cause mortality was higher in the long-term care group, whereas cardiovascular (CV) mortality was similar across groups. VARC-3 = Valve Academic Research Consortium-3.

• 

  Figure 2. Box-and-Whisker Plot of Perioperative Hospital Stay Duration Boxplot showing the length of hospital stay among 3 patient groups based on Long-Term Care Insurance status: noncertified, requiring support, and requiring long-term care. Median (Q1-Q3) total hospital stay was longest in the long-term care group (12.0 days [9.0-17.0 days] vs 13.0 days [10.0-19.0 days] vs 18.0 days [12.0-27.0 days], respectively; P < 0.001).

• 

  Figure 3. NYHA Functional Class at 1-Year Post-TAVR Based on LTCI Status NYHA functional class distribution for noncertified vs certified (long-term support/care) patients. Most surviving patients achieved NYHA functional class I or II status irrespective of the care dependence (88.6% vs 82.5% vs 85.2%; P = 0.727). LTCI = Long-Term Care Insurance; TAVR = transcatheter aortic valve replacement.

• 

  Figure 4. VARC-3 Unfavorable Outcome Based on LTCI Status (A) Patients were categorized into 3 groups: noncertified, requiring support group, and requiring long-term care group. Accordingly, the VARC-3 unfavorable outcome (death or NYHA functional class IV at 1 year) occurred in 8.7%, 6.9%, and 14.0% of the independent, support, and long-term care groups, respectively, with no statistically significant difference (P = 0.096). (B) A more detailed stratification according to individual support and care levels shows a trend toward increased incidence with higher care levels. A granular breakdown by individual support or care level is provided. Notably, even at the highest care level 5, >70% of patients remained free of the VARC-3 unfavorable outcome. LTCI = Long-Term Care Insurance.

• 

  Figure 5. Survival Curves After TAVR by LTCI Status (A) Kaplan-Meier survival curve stratified according to 3 groups: noncertified, requiring support (ie, Yo-Shien), and requiring long-term care (ie, Yo-Kaigo). (B) Kaplan-Meier curves for cardiovascular death-free survival stratified according to certification status. All-cause mortality was highest in the long-term care group, whereas the support and independent groups had comparable survival (log-rank test, P < 0.001). Cardiovascular death and heart failure rehospitalization were infrequent and similar across groups (P = 0.391). Abbreviations as in Figure 2.