Factors Contributing to Hospital-Associated Disability in Elderly Patients After Transcatheter Aortic Valve Implantation

Abstract

Background: Hospital-associated disability (HAD), characterized by a worsening of activities of daily living and physical function following hospitalization, is a common complication in older adults during the course of acute care hospitalization. HAD is a significant concern affecting older adults undergoing transcatheter aortic valve implantation (TAVI).

Methods and Results: This retrospective study investigated 243 consecutive patients who underwent elective transfemoral TAVI between January 2016 and April 2022. HAD was defined as a decrease of at least 1 point in the Short Physical Performance Battery (SPPB) assessed before discharge compared with before TAVI. Logistic regression identified the first ambulation day after TAVI as an independent predictor of HAD incidence (odds ratio 1.500; 95% confidence interval [CI] 1.115–2.008; P=0.007). Patients with HAD had significantly lower body mass index, hemoglobin, and albumin, and higher serum creatinine. All-cause mortality was significantly higher in patients with than without HAD (log-rank P<0.001). Kaplan-Meier analysis confirmed poorer survival in patients with HAD, regardless of the degree of decline in SPPB. Multivariate Cox analysis regression identified HAD as a predictor of all-cause death (hazard ratio 4.249; 95% CI 1.798–10.04; P<0.001).

Conclusions: The timing of the first ambulation was associated with the incidence of HAD. Promoting early mobilization may reduce the risk of HAD after TAVI.

Aging is a major global problem that is leading to an increase in various diseases, including aortic valve stenosis (AS). AS is a typical cardiac disease that emerges with aging, and open heart surgery has traditionally been the only curative treatment.¹ In recent years, transcatheter aortic valve implantation (TAVI) has been recognized as a suitable therapeutic option for patients with various surgical risk profiles.^2,3 Favorable mid- and long-term clinical outcomes have broadened the indications for TAVI, making it suitable for patients with intermediate and low surgical risk.^4–6

Hospital-associated disability (HAD) is characterized by worsening of activities of daily living (ADL) and physical function following hospitalization.⁷ HAD is a common complication in older adults during the course of acute care hospitalization. In previous studies, the prevalence of HAD among older adults hospitalized in acute care ranged from 17.1% to 43.6%.^7–9 Among cardiovascular patients, a nationwide registry survey in Japan found that the prevalence of HAD in elderly patients with heart failure was 37.1%.¹⁰ Furthermore, a meta-analysis reported that the prevalence of HAD was 30%,¹¹ and other studies have shown that HAD increases the risk of mortality after discharge.^12,13 In a previous study, 41.3% of patients with HAD died, and the rate of recovery from HAD was only 30.1% within 1 year of discharge.¹² HAD is also associated with a poor prognosis in patients with cardiovascular disease, including those with heart failure,¹⁴ and those who have undergone cardiovascular surgery.¹⁵ In addition, there are reports that HAD leads to a poor prognosis in patients undergoing TAVI.^16,17 However, reports of the relationship between HAD and the prognosis of patients undergoing TAVI remain insufficient.

Several studies have reported the risk factors for HAD in elderly patients, including age, poor physical function, lower grip strength, malnutrition, cognitive disorder, and reduced physical activity during hospitalization.^7,18–20 Risk factors for HAD in elderly patients with cardiovascular disease who have undergone cardiovascular surgery and who have heart failure have been reported in previous studies.^21,22 A recent study reported that non-lying time was associated with HAD in patients undergoing TAVI.²³ However, the understanding of which individuals who have undergone TAVI are at the greatest risk of HAD remains limited. Identification of key risk factors for HAD among patients who have undergone TAVI would advance our understanding of the pathogenesis of this important source of disability and could facilitate the development of novel strategies to prevent it.

In the present study, we investigated the association between HAD and prognosis, identified risk factors for HAD in patients undergoing TAVI, and examined effective interventions to prevent HAD and improve prognosis.

Methods

Study Design

This was a single-center retrospective study conducted at Osaka Metropolitan University Hospital (Osaka, Japan). We recruited 406 consecutive patients with symptomatic severe AS who were admitted to undergo elective transfemoral TAVI between January 2016 and April 2021 (Figure 1). Patients who could not undergo preoperative physical function assessment due to urgent medical conditions were excluded. Other exclusion criteria for this study were as follows: patients who died in hospital; patients unable to ambulate on admission; and patients whose physical function could not be assessed before discharge. Finally, 243 patients who underwent transfemoral TAVI were analyzed in this retrospective study.

Figure 1.

Study population. AS, aortic stenosis; TAVI, transcatheter aortic valve implantation; TF, transfemoral.

The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the institution’s human research committee. The study protocol was approved by the Institutional Ethics Committee of Osaka Metropolitan University (Approval no. 2020-223). The requirement for written consent was waived.

Data Collection

All data shown in the tables were collected retrospectively from patients’ medical records. Clinical data, including patient characteristics, echocardiographic findings, laboratory data, the type of prosthetic valve used, and procedural information, were collected. In addition, New York Heart Association (NYHA) functional class, which was used to assess heart failure symptom severity, and the Barthel Index, which was used to assess ADL, were collected from patients’ medical records. The surgical risk for AS was determined based on the Society of Thoracic Surgeons and European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) scores. In addition, we collected procedural and outcome information, including procedural time, anesthesia time, complications, first ambulation day after TAVI, in-hospital days, and discharge status. Complications after TAVI were evaluated as major adverse cardiac and cerebrovascular events (MACCE) and new pacemaker implantation. MACCE included stroke, bleeding, vascular complications, heart failure, and acute kidney injury. Data on all-cause mortality after TAVI were collected from patients’ medical records over a 2-year period. For patients who did not have outpatient records, we conducted telephone follow-up to determine whether they had died over a 2-year period.

Nutritional Data, Physical Function Data, and Frailty Data

Nutrition was evaluated by the Geriatric Nutritional Risk Index (GNRI),²⁴ Prognostic Nutritional Index,²⁵ and Mini Nutritional Assessment-Short Form.²⁶ Physical function data included muscle strength, gait speed, and the Short Physical Performance Battery (SPPB).²⁷ Grip strength and isometric knee extension strength were evaluated as muscle strength. Grip strength and isometric knee extension strength were evaluated as muscle strength. Grip strength was assessed using a handgrip dynamometer, and the isometric knee extension muscle strength-to-weight ratio (N/kg) was assessed using a handheld dynamometer with the patient sitting in a chair. Frailty data were evaluated according to the Clinical Frailty Scale (CFS).²⁸ All data were evaluated before TAVI.

HAD Definition

HAD is commonly defined as the new loss of ≥1 elements of basic ADL.⁷ In this study, HAD was defined as a decrease of at least 1 point in the SPPB assessed before discharge compared with the score obtained before TAVI.^17,23 The SPPB is a highly standardized physical function test consisting of 3 components: balance, gait speed, and muscle strength.²⁷ The total SPPB score ranges from 0 to 12 points, with a higher score indicating better physical function. A change in the SPPB score of 1 point is considered a meaningful change.²⁹ The SPPB is also often used as a physical function test for elderly patients because of related frailty and sarcopenia. The SPPB score was measured before TAVI and before discharge. Preprocedural SPPB was measured 1–3 days before the TAVI procedure and postprocedural SPPB was measured 7 days after the procedure.

Postprocedural Rehabilitation Program

We implemented a standardized postprocedural rehabilitation program for all patients who underwent TAVI, regardless of their preprocedural ADL levels. Postprocedural rehabilitation began as early as possible after TAVI and continued until discharge. The rehabilitation program followed the Japanese Circulation Society and Japanese Association of Cardiac Rehabilitation 2012 and 2021 guidelines on rehabilitation in patients with cardiovascular disease.^30,31 Protocols for the TAVI procedure at Osaka Metropolitan University Hospital are described in the Supplementary File.

Statistical Analysis

Normally distributed continuous variables are expressed as the mean±SD and were compared using Student’s t-test; non-normally distributed continuous variables are expressed as the median with interquartile range and were compared using the Mann-Whitney U test. The normality of data distribution was evaluated using the Shapiro-Wilk normality test. Categorical variables are presented as numbers and percentages and were compared using Fisher’s exact test. Logistic regression analysis was performed to assess the factors independently associated with the incidence of HAD. In the multivariate analysis, using the incidence of HAD as the dependent variable, the independent variables were chosen based on both the results of the univariate analysis and the findings of previous reports.^23,24 The results are expressed as odds ratios (ORs) and 95% confidence intervals (CIs). As a subgroup analysis to examine the impact of preprocedural functional level on the incidence of HAD, patients were divided into 2 groups based on a preprocedural SPPB cut-off score of 8. This cut-off was determined based on previous studies that identified an SPPB score of 8 as a criterion for frailty.³²

Kaplan-Meier curves were constructed for the time to death, and the log-rank test was used for initial comparisons. First, survival curves were compared between those with and without HAD. Then, the HAD group was further divided into 2 groups, one with a decline in the SPPB score of 1 point, and the other with a decline of ≥2 points. Univariate and multivariate Cox proportional hazards analyses were used to identify the predictors of all-cause death with adjustment for confounding factors. Univariate Cox proportional hazards analysis was performed using clinical variables including the incidence of HAD and generally recognized parameters influencing the incidence of HAD. The variables used in the multivariate analysis were selected based on the results of previous studies^7,19 and the univariate analysis. These variables were entered into the multivariate model to identify independent predictors of all-cause death. The results of the Cox proportional hazards models are presented as hazard ratios (HRs) and 95% CIs. All statistical analyses were performed using JMP 13 (SAS Institute Inc., Cary, NC, US). A two-tailed P value of <0.05 was considered statistically significant.

Results

Patient Population

Patient characteristics are presented in Table 1. According to the definition of a decrease in SPPB of at least 1 point, 82 (33.7%) of 243 patients had incident HAD after TAVI. The detailed numerical transitions, including the subcomponents of the SPPB in both groups, are presented in Supplementary Table 1. Comparing patients with and without HAD, there were no significant differences in age, sex, NYHA functional class, and Barthel Index score. Body mass index was significantly lower in patients with HAD. Comorbidities, preprocedural echocardiographic data, and surgical risk scores did not differ significantly. Preprocedural laboratory data showed that hemoglobin, serum sodium, and serum albumin were significantly lower and serum creatinine was significantly higher in patients with HAD.

Table 1.

Baseline Characteristics of the Patients With and Without HAD

	All patients (n=243)	Non-HAD (n=161)	HAD (n=82)	P value
Age (year)	83.7±4.7	83.4±4.6	84.3±4.9	0.178
Male sex	79 (32.5)	54 (33.5)	25 (30.5)	0.666
BMI (kg/m2)	23.1±4.0	23.7±3.9	22.1±4.0	0.004
NYHA Class III or IV	39 (16.0)	23 (14.3)	16 (19.5)	0.356
Barthel Index score	100 [90–100]	100 [90–100]	100 [85–100]	0.098
Comorbidity
Hypertension	224 (92.2)	129 (80.1)	64 (78.0)	0.738
Diabetes mellitus	64 (26.3)	41 (25.5)	23 (28.0)	0.758
Dyslipidemia	137 (56.4)	92 (57.1)	45 (54.9)	0.785
Atrial fibrillation	41 (16.9)	25 (15.5)	15 (19.5)	0.471
COPD	7 (2.9)	6 (3.7)	1 (1.2)	0.428
Laboratory data
Hemoglobin (g/dL)	11.5±1.6	11.7±1.5	10.9±1.6	<0.001
Serum sodium (mEq/L)	140.4±2.5	140.7±2.5	139.8±2.5	0.015
Albumin (g/dL)	3.8±0.4	3.9±0.4	3.7±0.4	0.025
Serum creatinine (g/dL)	0.98±0.38	0.94±0.31	1.06±0.47	0.023
BNP (pg/mL)	140.9 [65.4–277.8]	137.4 [65.4–277.8]	153.0 [65.3–276.6]	0.972
Baseline echocardiographic data
LVEF (%)	59.4±9.1	58.9±9.8	60.5±7.5	0.212
LAVI (mL/m2)	41.8±18.8	42.0±20.5	41.4±14.9	0.814
E/e′ ratio	23.4±8.7	23.1±8.6	24.2±9.0	0.364
AVA (cm2)	0.67±0.12	0.67±0.13	0.68±0.11	0.274
Mean AVPG (mmHg)	47.8±16.9	49.1±17.3	45.2±15.9	0.085
TRPG (mmHg)	24.6±8.4	23.9±8.5	26.1±7.9	0.068
Risk scores
STS score	6.2 [4.5–8.2]	6.1 [4.1–8.2]	6.3 [5.0–8.2]	0.238
EuroSCORE II	3.7±2.5	3.7±2.3	3.9±2.8	0.413
Nutritional data
GNRI score	96.5±7.8	97.7±7.6	94.1±7.8	<0.001
PNI score	44.8±5.4	45.2±5.4	43.8±5.0	0.033
MNA-SF score	11 [10–13]	12 [10–13]	11 [9–12]	0.008
Physical functional data
Hand grip strength (kg)	18.9±6.6	19.6±6.9	17.5±5.5	0.016
Knee extension strength (N/kg)	3.81±1.12	3.86±1.16	3.70±1.05	0.277
Gait speed (m/s)	0.80±0.25	0.82±0.26	0.76±0.22	0.071
SPPB score	9 [6–11]	9 [6–11]	9 [7–11]	0.555
Frailty data
Clinical Frailty Scale	4 [3–4]	3 [2–4]	4 [3–4]	0.031

Unless indicated otherwise, values are given as the mean±SD, median [interquartile range], or n (%). AVA, aortic valve area; AVPG, aortic valve pressure gradient; BMI, body mass index; BNP, B-type natriuretic peptide; COPD, chronic obstructive pulmonary disease; E/e′, ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity; eGFR, estimated glomerular filtration rate; EuroSCORE II, European System for Cardiac Operative Risk Evaluation II; GNRI, Geriatric Nutritional Risk Index; HAD, hospital-associated disability; LAVI, left atrial volume index; LVEF, left ventricular ejection fraction; MNA-SF, Short-Form Mini-Nutritional Assessment; NYHA, New York Heart Association; PNI, Prognostic Nutritional Index; SPPB, Short Physical Performance Battery; STS, Society of Thoracic Surgeons; TRPG, tricuspid regurgitation pressure gradient.

The preprocedural nutritional, frailty, and physical function data are presented in Table 1. All indicators evaluated for nutrition were significantly lower and the CFS score was significantly higher in patients with HAD. Preprocedural physical function data showed that handgrip strength was significantly lower in patients with HAD. However, the isometric knee extension muscle strength-to-weight ratio, gait speed, and SPPB score were not significantly different between patients with and without HAD. Our analysis revealed no significant differences in the trends of SPPB changes between these 2 groups (Supplementary Table 1). In subgroup analyses, there were no differences between low or high levels of physical functioning with regard to the incidence of HAD (Supplementary Table 2).

The procedural and outcome data are presented in Table 2. There were no significant differences in procedural data, such as procedural time and anesthesia time, between patients with and without HAD. In terms of outcomes, the first ambulation day after TAVI was significantly delayed, the number of in-hospital days was significantly longer, and the rate of transfer to other healthcare institutions was significantly higher in patients with HAD. Forty-five patients did not achieve their first ambulation on postprocedural day 1; of these, 27 were in the HAD group and 18 were in the non-HAD group. The primary reasons for delayed ambulation included worsening subjective symptoms and hemodynamic issues (Supplementary Table 3). Postprocedural complications, MACCE, and new pacemaker implantations did not differ significantly between patients with and without HAD. The types of prosthetic valves used for TAVI are presented in Supplementary Table 4. There were no significant differences between the HAD and non-HAD groups.

Table 2.

Procedural Data and Outcome Information

	All patients (n=243)	Non-HAD (n=161)	HAD (n=82)	P value
Procedural data
Procedural time (min)	78.4±40.1	75.5±33.7	84.2±50.0	0.109
Anesthesia time (min)	131.3±67.9	130.8±72.1	132.3±57.1	0.867
Periprocedural complications
New PMI in hospital	9 (3.7)	3 (1.8)	6 (7.3)	0.065
MACCE	38 (15.6)	26 (16.1)	12 (14.6)	0.853
Stroke	3 (1.2)	1 (0.6)	2 (2.4)
Bleeding	17 (7.0)	7 (4.3)	10 (12.1)
Vascular complication	13 (5.3)	7 (4.3)	6 (7.3)
Heart failure	10 (4.1)	3 (1.9)	7 (8.5)
AKI	7 (2.9)	2 (1.2)	5 (6.0)
Postprocedural outcome
First ambulation day (POD)	1 [1–1]	1 [1–1]	1 [1–2]	<0.001
First ambulation on the day after the procedure	198 (81.4)	143 (88.8)	55 (67.1)	<0.001
Postprocedural length of hospital stay (days)	10 [8–12]	10 [8–12]	11 [9–16]	<0.001
Transfer to another facility	18 (7.4)	9 (3.8)	12 (14.6)	0.004

Unless indicated otherwise, values are given as the mean±SD, median [interquartile range], or n (%). AKI, acute kidney injury; HAD, hospital-associated disability; MACCE, major adverse cardiac and cerebrovascular events; PMI, pacemaker implantation; POD, postoperative day.

Association Between HAD and Clinical Course

Overall, 17 patients died during the 2-year follow-up after TAVI. Kaplan-Meier survival curves for patients with and without HAD are shown in Figure 2. The all-cause mortality rate was significantly higher for patients with than without HAD (log-rank test P<0.001; Figure 2A). Kaplan-Meier survival curves after dividing patients with HAD into 2 groups according to the degree of SPPB decline are shown in Figure 2B. The group with a decline of 1 point in the SPPB score (mild HAD) and the group with a decline or ≥2 points in the SPPB score (severe HAD) had a significantly higher all-cause mortality rate than the group without HAD. However, there was no significant difference in all-cause mortality between the groups with mild and severe HAD.

Figure 2.

Kaplan-Meier estimates of risk of all-cause death. (A) The rate of all-cause mortality was significantly (log-rank P<0.001) higher for patients with than without hospital-associated disability (HAD). (B) Rates of all-cause mortality were higher in the groups with mild (1-point decline in the Short Physical Performance Battery [SPPB]) and severe (≥2-point decline in the SPPB) HAD than in those without HAD. There was no significant difference in mortality between the mild and severe HAD groups.

Univariate Cox regression analysis showed that the incidence of HAD was significantly associated with a higher incidence of all-cause death (HR 5.084; 95% CI 2.210–11.70; P<0.001). In addition, the multivariate Cox regression analysis using the forced inclusion model with age, GNRI, and the incidence of HAD identified the incidence of HAD as a significant predictor of all-cause death (HR 4.249; 95% CI 1.798–10.04; P<0.001; Table 3).

Table 3.

Univariate and Multivariate Analyses for All-Cause Death

	Univariate analysis			Multivariate analysis
	HR	95% CI	P value	HR	95% CI	P value
Age	0.925	0.859–0.996	0.040	0.914	0.855–0.978	0.009
Male sex	2.227	1.032–4.805	0.041
NYHA Class III or IV	0.970	0.334–2.814	0.955
Barthel Index	1.010	0.967–1.055	0.652
STS score	1.001	0.910–1.113	0.902
LVEF	0.981	0.946–1.170	0.289
E/e′	1.048	1.012–1.086	0.009
AVA	0.609	0.025–16.160	0.763
Mean AVPG	1.008	0.986–1.031	0.480
TRPG	1.028	0.993–1.065	0.122
LAVI	1.006	0.989–1.023	0.505
Hemoglobin	0.863	0.675–1.103	0.239
Serum sodium	0.844	0.736–0.967	0.143
Serum creatinine	1.952	0.887–4.297	0.096
Log BNP	3.467	1.306–9.205	0.013
GNRI	0.939	0.902–0.989	0.003	0.947	0.903–0.992	0.022
Hand grip strength	0.998	0.941–1.059	0.950
Knee extension strength	0.935	0.653–1.338	0.712
Gait speed	0.761	0.168–3.440	0.723
SPPB	1.005	0.879–1.150	0.938
Clinical Frailty Scale	1.097	0.693–1.736	0.693
Procedural time	0.997	0.986–1.008	0.568
Anesthesia time	1.002	0.999–1.005	0.142
MACCE	1.019	0.351–2.958	0.972
New PMI in hospital	0.974	0.132–7.192	0.980
HAD	5.084	2.209–11.700	<0.001	4.249	1.798–10.040	<0.001

CI, confidence interval; HR, hazard ratio. Other abbreviations as in Tables 1,2.

Predictive Variables for HAD

The results of univariate and multivariate logistic regression analyses are presented in Table 4. In univariate analysis, among the preprocedural factors, hemoglobin, serum sodium, creatinine, GNRI, hand grip strength, and CFS were associated with the incidence of HAD. Among the postprocedural factors, the first ambulation day after TAVI and new pacemaker implantation were associated with the incidence of HAD. Age, preprocedural AS severity, and preprocedural heart failure severity assessed by B-type natriuretic peptide were not predictors of the incidence of HAD.

Table 4.

Univariate and Multivariate Analyses for the Incidence of HAD

	Univariate analysis			Multivariate analysis
	OR	95% CI	P value	OR	95% CI	P value
Age	1.041	0.982–1.103	0.179
Male sex	0.869	0.490–1.541	0.631
NYHA Class III or IV	1.455	0.721–2.936	0.296
Barthel Index	0.980	0.953–1.007	0.141
STS score	1.041	0.968–1.120	0.280
LVEF	1.020	0.989–1.053	0.213
E/e′	1.014	0.984–1.046	0.363
AVA	3.408	0.379–30.657	0.274
Mean AVPG	0.986	0.969–1.002	0.087
TRPG	1.031	0.997–1.065	0.076
LAVI	0.998	0.984–1.013	0.813
Hemoglobin	0.697	0.578–0.840	<0.001	0.812	0.649–1.015	0.669
Serum sodium	0.877	0.788–0.977	0.017	0.893	0.797–1.001	0.052
Serum creatinine	2.200	1.090–4.450	0.028	1.938	0.855–4.390	0.113
Log BNP	1.000	0.999–1.001	0.725
GNRI	0.943	0.910–0.977	0.001	0.970	0.932–1.011	0.152
Hand grip strength	0.947	0.906–0.991	0.019	0.985	0.930–1.043	0.067
Knee extension strength	0.873	0.686–1.110	0.273
Gait speed	0.369	0.124–1.095	0.072
SPPB	1.048	0.954–1.152	0.328
Clinical Frailty Scale	1.460	1.050–2.040	0.025	1.187	0.799–1.764	0.398
Procedural time	1.005	0.999–1.012	0.117
Anesthesia time	1.000	0.996–1.004	0.867
MACCE	0.890	0.424–1.870	0.759
New PMI in hospital	4.158	1.012–17.076	0.048
First ambulation day	1.690	1.210–2.350	0.002	1.500	1.115–2.008	0.007

CI, confidence interval; OR, odds ratio. Other abbreviations as in Tables 1,2.

The multivariate analysis was performed using factors that were significant in the univariate analysis. In the multivariate analysis, only the first ambulation day after TAVI was an independent predictor of the incidence of HAD after TAVI (OR 1.500; 95% CI 1.115–2.008; P=0.007). We also investigated the impact of postprocedural complications on the incidence of HAD. The results of the univariate and multivariate analyses are presented in Supplementary Table 5. After adjusting for postprocedural complications, the first ambulation day was identified as an independent predictor of HAD (OR 1.570; 95% CI 1.100–2.230; P=0.012).

Discussion

This study demonstrated that the incidence of HAD has an important prognostic impact in patients undergoing TAVI, and we identified independent predictors of the incidence of HAD. To the best of our knowledge, this is the first report to demonstrate the association between the first ambulation day after TAVI and the incidence of HAD in patients undergoing TAVI. Previous research has indicated that the first ambulation day influences the incidence of HAD in patients with cardiovascular diseases.^21,22 Thus, our finding that the first ambulation day after TAVI led to the onset of HAD is consistent with previous research in other cardiovascular diseases.

Among patients undergoing cardiac surgery, it has been reported that early ambulation after surgery is associated with a longer walking distance during hospitalization.³³ Given this report, the factors related to the first ambulation day and the incidence of HAD can be linked to the level of physical activity during hospitalization. In a previous study, physical inactivity during hospitalization was associated with compromised recovery of ADL in patients with acute medical illness.³⁴ This association remained consistent for patients with both low and high levels of ADL prior to hospitalization. Based on these findings, a delayed initiation of ambulation after TAVI may prolong physical inactivity, leading to deconditioning. Other reports exist concerning the correlation between low physical activity during hospitalization and HAD. In the study of Pavon et al., there was a significant association between in-hospital physical activity and HAD.²⁰ In contrast, Tasheva et al. reported no such connection, suggesting that the topic remains open for discussion.³⁵ A relationship between physical activity and the onset of HAD in patients undergoing TAVI was reported in a recent study.²³ However, that is the only report on the physical activity of patients undergoing TAVI, and the report measured physical activity during hospitalization as lying time or non-lying time. Therefore, the relationship between physical activity (e.g., the duration of standing, number of steps) and the onset of HAD in these patients remains ambiguous. Future research should evaluate the relationship between physical activity and HAD following TAVI.

HAD is known to present various challenges, including difficulties in recovery that can lead to poor prognoses.¹² A previous study indicated that the onset of HAD correlates with all-cause mortality 3 years after TAVI,¹⁷ a finding that aligns with the results of the present study. Furthermore, it is interesting to note that the prognosis of TAVI was not related to the degree of physical function decline among the group with HAD. This insight provides evidence indicating that postprocedural physical function decline, even if mild, is detrimental, emphasizing the importance of maintaining physical function, or preventing HAD, to improve prognosis in patients undergoing TAVI.

In a previous report with a 1-year follow-up of patients who developed HAD after an acute illness and who were subsequently discharged, only 30.1% returned to their prehospitalization level of ADL.¹² Among the remaining patients, 28.6% had not recovered their prehospitalization ADL function at 1 year and 41.3% died.¹² Thus, preserving physical function after TAVI is paramount for ensuring a favorable prognosis.

Previous studies have proposed various preventive measures against HAD. For instance, the Acute Care for Elders (ACE) model, a comprehensive intervention designed to prevent HAD in elderly patients with acute illness, has been proposed.³⁶ A systematic review and meta-analysis of the ACE model reported several benefits, such as fewer falls, reduced incidence of delirium, improved functional outcomes, and shorter hospital stays.³⁷ Considering that TAVI primarily targets older and high-risk individuals and the length of hospital stay for TAVI is typically shorter than that for open heart surgery,³⁸ the ACE model may be pivotal in preventing HAD in this demographic. Therefore, there is a clear need for early mobilization and comprehensive interventions, such as the ACE model, even after TAVI, to reduce the risk of HAD and ensure a favorable prognosis.

Study Limitations

This study has several limitations. As a single-center retrospective study with a limited sample size, it is insufficient to establish causality while accounting for potential confounders. Furthermore, some patients were excluded due to missing data, introducing the possibility of selection bias. Thus, multicenter large-scale prospective trials are required to further improve the objectivity of the findings. This study defined HAD as a decrease of at least 1 point in the SPPB score assessed before discharge compared with the score obtained before TAVI. However, previous studies have used alternative definitions of HAD. Therefore, the definition of HAD is controversial and it cannot be ruled out that the definition of HAD may have influenced the outcomes.

Conclusions

The timing of the first ambulation was associated with the incidence of HAD after TAVI. Promoting early mobilization may enhance physical activity during hospitalization and reduce the risk of HAD after TAVI.

Acknowledgments

The physical function data were obtained by Shota Takemoto and Eiji Tamura, who are physiotherapists at Osaka Metropolitan University Graduate School of Medicine. The authors thank Emily Woodhouse, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

Sources of Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosures

D.F. is a member of Circulation Journal’s Editorial Team. The remaining authors have no conflicts of interest to declare.

IRB Information

The study protocol was approved by the Institutional Ethics Committee of Osaka Metropolitan University (Approval no. 2020-223).

Data Availability

The deidentified participant data will be shared on a request basis. Please contact the corresponding author directly to request data sharing. All datasets used in this study are available for meta-analyses only. Data sharing requires approval from the IRB of Osaka Metropolitan University Graduate School of Medicine. The data will remain accessible until December 2030 and will be shared exclusively with researchers involved in TAVI-related studies. Data will be shared as Excel files via email.

Supplementary Files

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-24-0710

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