Clinical Evaluation and Geriatric Assessment in Elderly Patients Before and After Percutaneous Aortic Valve Implantation (TAVI) or MitraClip Positioning

Aortic stenosis (AS) is a progressive chronic valvular disease that progressively and rapidly leads to the development of heart failure. This pathology, which is typical of the elderly, is increasing together with the age of the population and it is a candidate for the development of less invasive and innovative therapies that enable the treatment of older patients with polypathology and high degree of comorbidity. According to the most recent guidelines for the treatment of valvular heart disease, the degenerative AS is the most common valve disease in Western countries especially in the group aged over 65 years. The degenerative AS, in its most severe form, is a highly debilitating chronic condition characterized by symptoms as such precordial pain suggestive of angina, transient altered state of consciousness, or syncope, dyspnea and other heart failure symptoms secondary to reduced stroke volume. A recent systematic review (2) estimated the prevalence of AS in the elderly population aged over 75 years amounted to 12.4% while the prevalence of severe AS amounted to 3.4%. The average survival after the onset of symptoms is about 2-3 years. The natural history of the disease is not modified by conservative treatment and, to date, the surgical aortic valve replacement is recommended by both the American and European guidelines for patients with severe symptomatic and asymptomatic patients with reduced ejection fraction (80 years obtain appreciable results with a less than 10% mortality and morbidity between 5 and 10%. Some conditions, such as the presence of comorbidities (chronic obstructive pulmonary disease, vasculopathy, chronic renal failure, dementia and other) and the advanced age of the patients, make the surgery too risky or impossible to achieve. Therefore, approximately one third of patients in advanced age is not currently subjected to surgery.

After the "first man" made in 2002, TAVI has been introduced in the clinic in 2007 and has quickly gained critical acclaim. Up to now, about 150,000 TAVI procedures were performed with a growing trend.

The methodical approach of the techniques involve various approaches: transfemoral, transapical, (the two most popular), transaxillary, transaortic.

The enormous diffusion of the method follows the growing demand. Conservative treatment of the SA guarantees any improvement; optimized drugs therapy is able nor to mitigate the symptomatology associated nor to resolve the underlying disease.

The surgery requires the use of extracorporeal circulation and, although conducted in the less invasive way possible, it remains an intervention in which elderly patients with polypathology and high degree of comorbidity are hardly addressed.