Frailty in patients with aortic stenosis awaiting intervention

Aortic stenosis (AS) is a common valvular disease in older age. Definitive interventions include surgical aortic valve replacement or transcatheter aortic valve implantation (TAVI). In high-risk patients, frailty is observed in up to 50% awaiting TAVI. Frailty is now an established predictor of outcomes in patients with AS who undergo intervention. There is currently no consensus definition for frailty. It is widely described as a syndrome of loss in physiological reserve predisposing to increased vulnerability for death or dependency. Frailty encompasses a holistic view including domains of physical function, cognition, depression, nutrition and medical comorbidities. Individual components of frailty have been shown to significantly predict mortality, functional recovery and quality of life after TAVI. The addition of frailty components to conventional risk prediction models traditionally used in cardiac surgery has been shown to augment overall prediction for post-operative mortality and morbidity. Identifying patients who are frail at baseline provides an opportunity to modify dynamic aspects of frailty prior to, and after definitive intervention for AS. A multidisciplinary approach including comprehensive geriatric pre-operative assessment will likely become standard of care to identify and optimise frail patients awaiting TAVI. In this review, we discuss the definition and measurement of frailty in patients with AS, evaluate recent data on risk prediction associated with frailty, and outline approaches to optimisation of dynamic components of frailty to improve outcomes after AS intervention.