In clinical practice, this patient population is complex, often presenting with multiple comorbidities and unique functional, cognitive, and social characteristics that may or may not correlate with their chronological age. The available literature on this topic is highly heterogeneous, prompting the collaboration of various participants from European societies involved in this effort to establish a consensus document on the evaluation and management of frailty in patients undergoing TAVI or cardiac surgery. 

A multidisciplinary working group was created, comprising surgeons, cardiologists, geriatricians, and anesthesiologists, all of whom declared the absence of conflicts of interest. A biostatistician participated as an advisor for the literature review and methodology development process. A systematic review was conducted in Medline, using search terms that included frailty assessment, transcatheter aortic valve interventions, and cardiac surgical procedures. The primary inclusion criterion required that studies evaluate the predictive ability of a specific frailty assessment tool for one of the outcomes of interest. 

Articles meeting inclusion criteria were reviewed independently by two researchers, with a third researcher resolving any discrepancies. Out of 1,181 publications reviewed, 254 were included in the final analysis. Given the wide variety of tools investigated and the methodological heterogeneity, the researchers reached a consensus by considering the frequency with which certain tools were described and their demonstrated success in predicting specific outcomes. These findings were complemented by the expertise of the working group members. 

The following points summarize the key findings of the consensus: 

1. Frailty and Outcome Prediction After Cardiac Surgical Procedures: 

Frailty is a predictor of short-term (30 days), medium-term, and long-term (1 year) mortality following cardiac surgery, as well as neurological complications, delirium, and length of hospital stay. Traditional risk scales such as EuroSCORE and STS tend to underestimate surgical risk as they do not incorporate frailty parameters. The tools recommended are based on studies with large sample sizes (n > 10,000): 

• Gait Speed (5 meters): Recommended as a predictor of perioperative, medium-, and long-term mortality following cardiac surgery. 

• 6-Minute Walk Test: Useful specifically for predicting medium-term mortality, particularly in patients being assessed for heart failure. 

• Katz Index of Activities of Daily Living (0 points: total dependence, 6 points: maximum independence):Identified as an independent predictor of mortality in 2 of 6 studies but not recommended as a predictive tool. 

• Psoas Muscle Area Index (PAI) and Sarcopenia Evaluation:
  Sarcopenia correlates with frailty. PAI is recommended for medium- and long-term mortality prediction in cardiac surgery patients, but not for perioperative mortality. Tools such as CT or bone densitometry can be used to assess mortality risk. Additionally, PAI predicts prolonged hospital stay and discharge to intermediate care or non-home settings. 

• Fried’s Frailty Phenotype (3 or more positive criteria):
  A valid tool for predicting all types of mortality, postoperative delirium, prolonged hospital stay, quality of life, and the likelihood of hospital readmission or discharge to intermediate care. 

• Clinical Frailty Scale (CFS): A simple, non-instrumental classification (1: athletic/robust, 7: completely dependent) recommended for predicting short- and medium-term mortality, but not long-term mortality. 

• Short Physical Performance Battery (SPPB): Assesses balance, gait speed, and chair stand test. Predicts medium-term mortality and prolonged hospital stay. 

• Edmonton Frail Scale (EFS, 0: no frailty, 12-17: severe frailty): Could be used to predict prolonged intensive care unit stays. 

• Cognitive Assessments:
  Tools such as the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are effective in estimating delirium risk in this patient profile. 

2. Frailty and Outcome Prediction After TAVI Procedures
Frailty is a predictor of short-, medium-, and long-term mortality after transcatheter aortic valve implantation (TAVI). The recommended assessment tools include: 

• Gait Speed (5 meters): Recommended for medium- and long-term mortality prediction and, to a lesser extent, short-term mortality. It also predicts prolonged hospital stays and post-TAVI delirium. 

• Serum Albumin: A concentration below 3.5 g/dL predicts medium- and long-term mortality. 

• Katz Index of Activities of Daily Living (ADL): Useful as a predictor of short-, medium-, and long-term mortality. This is not the case for the Lawton Index (instrumental ADLs). 

• Handgrip Strength: Assessed using a dynamometer, it is a predictor of medium-term mortality in this group. 

• CFS and Psoas Muscle Area (as measured by CT): Recommended for predicting short- and long-term mortality. Additionally, the Bern Scale (5 items) is suggested for evaluating these parameters. 

• Mini-Mental State Examination (MMSE): Limited evidence supports its use as a predictor of long-term mortality, and data on short-term mortality are inconsistent. However, it is useful for predicting post-TAVI delirium. 

Frailty as a Predictor of Neurological Complications, Delirium, and Prolonged Hospitalization/Ventilation After TAVI

• Nutritional Status: Poor nutrition is strongly correlated with postoperative complications and delayed recovery. Serum albumin is a reliable indicator of nutritional status, while body mass index (BMI) shows inconsistent results. 

• Gait Speed (5 meters): A predictor of neurological complications and prolonged hospital stays. 

• MMSE: Useful in predicting delirium risk during hospital stays, often resulting in extended hospitalization. 

• Sarcopenia Assessment (Psoas Muscle Measures): Strongly predicts prolonged hospital stays; routine CT scans can easily provide this data. 

Frailty as a Predictor of Quality of Life, Discharge Location, Readmission, and Functional Decline After TAVI

• CFS, Fried Criteria, and Gait Speed (5 meters): Predictors of quality of life, especially for defining discharge to locations other than the patient’s home. 

• Fried Criteria and Gait Speed: These also help predict hospital readmission and functional decline post-TAVI. 

 3. Management of Frail Patients and Integration of Frailty Assessment in Routine Clinical Practice 

• Use of Serum Markers:
  Parameters such as serum albumin have been analyzed in several studies as indirect indicators of frailty. Comprehensive nutritional assessments incorporating serum albumin levels are highlighted as potential tools for evaluating patient status. This remains an open field for further research. 

• Using Diagnostic Records to Identify Frail Patients:
  Identifying frailty through a scoring system that groups established diagnoses related to frailty could be an interesting proposal. However, no validated model is currently available. 

• Prehabilitation:
  Once frailty is identified, the next step involves reducing or managing its impact through prehabilitation programs. These include strength training exercises, respiratory muscle training, nutritional interventions, and health education. Moreover, social and cognitive aspects are integrated, such as cognitive-behavioral therapy for patients with prior anxiety disorders, which has been shown to decrease hospital stay, reduce depressive symptoms, and improve perceived quality of life within four weeks post-discharge. These interventions yield positive outcomes but require additional studies for validation. 

The evaluation of frailty has become an essential tool for estimating perioperative/interventional risk on an individualized basis. It also provides insights into quality of life and reduces the likelihood of institutionalization. This working group conducted a thorough literature review to produce a consensus statement on assessing frailty to predict outcomes such as in-hospital mortality, length of stay, readmission, neurological sequelae, and quality-of-life parameters. Frailty evaluation, result interpretation, and decision-making should always be performed within a multidisciplinary team. 

COMMENTARY:

The population is not only aging chronologically but also presenting with increased complexity, which must not be overlooked in clinical practice. These challenges, perceived by all healthcare professionals, urge us to seek high-quality consensus documents to ensure optimal interventions. The summarized results provide highly relevant guidelines for multidimensional patient evaluation (already selected for these procedures but potentially classified as robust, pre-frail, or frail). Consolidating these tools and corroborating their predictive value serves as an excellent starting point for implementing improvement measures. 

Frailty is one of the major challenges in geriatrics, highly prevalent among elderly patients treated by medical and surgical specialties beyond geriatrics. This growing demand for care fosters the concept of transversal geriatrics, applying geriatric medicine principles in non-geriatric units to ensure a multidisciplinary approach in other services. Comprehensive geriatric assessments and frailty detection in these patients provide prognostic information, aid decision-making, and support tailored treatment selection. The shared objective is person-centered care with optimized comprehensive management—a reality that will continue to expand across more hospitals. Geriatricians consider this a significant healthcare challenge of the 21st century. 

REFERENCE: 

Sündermann SH, Bäck C, Bischoff-Ferrari HA, Dehbi HM, Szekely A, Völler H, et al. Preinterventional frailty assessment in patients scheduled for cardiac surgery or transcatheter aortic valve implantation: a consensus statement of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Preventive Cardiology (EAPC) of the European Society of Cardiology (ESC). Eur J Cardiothorac Surg. 2023 Oct 4;64(4):ezad181. doi: 10.1093/ejcts/ezad181.