1Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; 2Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland
Background: Selection of patients who will benefit from transcatheter edge-to-edge mitral and tricuspid valve repair (TMTVR) is challenging due to complex underlying comorbidity. Current guidelines recommend frailty assessment for risk stratification, but it is unclear which score is most appropriate. We evaluated an adapted version of the Essential Frailty Toolset (EFT) for risk stratification in these patients.
Methods: We performed a retrospective analysis of a prospective cohort study of patients who received TMTVR between 5/2017 and 12/2019. An adapted version of the EFT was calculated from 4 categories: (1) gait speed, (2) cognitive impairment, (3) haemoglobin and (4) serum albumin (Table). According to their individual EFT score, patients were classified as non-frail (0 points), pre-frail (1-2 points) or frail (3-5 points). The median follow-up time for survival was 490 days (IQR: 295 to 624 days). Results: Data of 206 patients were analysed. Mean age was 76±10 years, 55% were male, baseline parameters and comorbidities were similar to other study populations of patients undergoing TMTVR. According to the EFT, 49 patients (24%) were non-frail, 127 patients (62%) were pre-frail and 30 patients (15%) were frail. During follow-up 41 patients (20%) died. Mortality was higher in patients with higher EFT scores: Estimated survival at 2 years was 88±5% for non-frail patients, 74±5% for pre-frail patients and 62±10% for frail patients (Figure). Each incremental EFT point was associated with a hazard ratio of 1.49 (1.14-1.93; p=0.003). This association remained significant after adjustment for age, EuroScore II, peripheral artery disease, diabetes and physical frailty according to Fried criteria (hazard ratio 1.36 [1.04-1.78]; p=0.025).
Conclusion: This is the first study to demonstrate that the EFT score provides strong and additive prognostic information beyond cardiovascular risk factors and physical frailty in patients undergoing TMTVR. As it is pragmatic and easier to assess than other multidimensional frailty scores, it could be used in daily routine as a basis for informed decision making. In the clinical setting, it may also help to identify patients who would benefit from targeted interventions such as early cardiac rehabilitation or dietary optimisation.
Table: Adapted Essential Frailty Toolset (EFT)
| EFT-Category | Cutoff value | Point distribution | Number of patients (n=206) (%) |
| Lower body strength (gait speed 4,5m) | >1m/s 1m/s-0,6m/s <0,6m/s | 0 points 1 point 2 points | 84 (41) 81 (39) 41 (20) |
| Cognitive impairment (Short portable mental status questionnaire) | 0-3 mistakes ≥4 mistakes | 0 points 1 point | 200 (97) 6 (3) |
| Baseline haemoglobin | ≥ 13.0 g/dl ♂ ≥ 12.0 g/dl ♀ < 13.0 g/dl ♂ < 12.0 g/dl ♀ | 0 points 1 point | 109 (53) 97 (47) |
| Baseline serum albumin | ≥ 35.0 g/l < 35.0 g/l | 0 points 1 point | 188 (91) 18 (9) |