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Page 2 of 8 Antonazzo et al. Vessel Plus 2020;4:3 I http://dx.doi.org/10.20517/2574-1209.2019.33

role of multidimensional assessment of elderly patients scheduled for TAVI, in order to maximize its appropriateness,
effectiveness, and safety.

Conclusion: It is crucial to consider frailty scores, as well as nutrition and functional status, in addition to established
surgical risk scores, in elderly patients considered for TAVI to improve risk prediction, reinforcing the favorable impact of
this therapy to improve cognitive function.

Keywords: Aortic stenosis, elderly, transcatheter aortic valve implantation, transcatheter aortic valve replacement

INTRODUCTION
Surgical aortic valve replacement (SAVR) has been for several decades the default management strategy for
[1]
severe aortic stenosis in fit patients . However, an ever increasing elderly population, often fraught with
[2]
substantial comorbidities, has challenged in many cases the risk-benefit profile of surgery . Accordingly,
[3]
less invasive strategies were developed, including balloon aortic valvuloplasty .
Building upon developments in materials and procedures, and inspired by breakthrough results of stenting
for coronary and endovascular procedures, transcatheter aortic valve implantation (TAVI), also called
[4-6]
transcatheter aortic valve replacement (TAVR), was introduced by Alain Cribier almost two decades ago .
The successes of TAVI have been dramatic indeed, as poignantly summarized by the recent US Food and
[7]
Drug Administration approval of new-generation devices for TAVI even in patients at low surgical risk .
However, TAVI continues to be considered and used mostly for elderly patients, given the uncertainty on
[8]
long-term and very long-term device durability .

Despite the evidently favorable risk-benefit profile of TAVI in general, and in the elderly in particular,
several areas of investigation and debate persist, typically focusing on indication, timing, procedural
[6]
aspects, device choice, ancillary medical management, and post-procedural results . We aimed at
exploiting the synthesizing power of umbrella review studies to reconcile conflicting sources of evidence
[9]
on TAVI in the elderly, in order to inform current practice and guide future research .

METHODS
This scoping umbrella review was conducted in keeping with best practice recommendations, and reported
[9]
accordingly . Specifically, we used a multifaceted approach for evidence accrual, avoiding a specific
or restrictive definition of elderly. First, PubMed was searched using the following string: “{elderly OR
octogenarian* OR octagenarian* OR nonagenarian* OR old OR aged OR [age AND (advanced OR old)]}
AND transcatheter AND aortic AND valve AND (implantation OR replacement) AND systematic[sb]” up
to 31 October 2019. Accordingly, any review detailing on, at least in part, nonagenarians, octogenarians,
aged patients, or subjects with advanced or old age could be included, provided it also focused on TAVI.
Thereafter, we used backward and forward snowballing to identify additional citations. Afterwards,
potentially relevant citations were screened at the title/abstract level. Potentially relevant hits were then
retrieved as full-texts.

We included systematic reviews (i.e., overviews of published clinical studies including two or more primary
original reports) detailing TAVI in elderly patients (defined as people aged ≥ 65), irrespective of their focus
on diagnosis, prognosis, device choice, procedural aspects, or outcomes, to avoid being overly restrictive.
Several domains were abstracted, including review features, study aspects, and other details on included
patients, procedures, and outcomes. Review validity was appraised with the Oxman and Guyatt Overview
[10]
Quality Assessment Questionnaire . All reviewing activities were performed by two independent
reviewers, with divergences solved after consensus.