Updates of developments in interventional therapy for elderly patients with cardiovascular diseases

Hua SHEN,Xun-Xun FENG,Qian-Yun GUO,Yu-Jie ZHOU

Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease,Beijing Institute of Heart Lung and Blood Vessel Disease,Clinical Center for Coronary Heart Disease,Department of Cardiology,Beijing Anzhen Hospital,Capital Medical University,Beijing,China

Cardiovascular diseases (CVD) are the leading cause of death in the world and one of the most common diseases in the elderly,with high prevalence and poor prognosis,which seriously affect the health of the elder patients.One report showed that global deaths from CVD increased from 12.4 million in 1990 to 19.8 million in 2022,reflecting the global population growth and aging,as well as the impact of metabolic,environmental,and behavioral risks.[1]With the progress of aging population,the burden of CVD in the elderly in China has increased year by year,and factors including multiple complications,organ function decline,and high complication rate have made the interventional treatment of CVD in the elderly one of the difficulties and focuses in the field of cardiology in China.

The elderly are growing exponentially in the 21stcentury,and coronary artery disease (CAD) is an important cause of morbidity and mortality in this aged population.[2]With the aging population,the proportion of CVD patients in the elderly is increasing.The unique clinical characteristics in the elderly patients,including more comorbidities,more complex coronary anatomy,higher risks of myocardial infarction and complications,and multiple combination regimens,make CAD management more challenging compared to younger patients.[3]Considering the lack of data on the elderly population,it is necessary to more accurately determine the specific risks brought by interventions.At present,coronary interventional therapy has entered an era of “precision diagnosis and treatment”,through the application of intravascular ultrasound (IVUS),optical coherence tomography (OCT),and other intravascular imaging techniques,which can reflect the intravascular structure and determine the type and severity of lesions,to better guide the interventional procedures and optimize the clinical outcomes.Numerous studies(such as RENOVATE-COMPLEX-PCI,IVUS-XPL,ULTIMATE,and OCTIVUS) have shown that intravascular imaging-guided percutaneous coronary intervention (PCI) significantly reduces the risk of adverse events compared to coronary angiography(CAG) guided PCI.Meanwhile,with the continuous development of medical imaging technology,imaging functional evaluation will play an increasingly important role in the diagnosis and treatment of CAD,including the application of machine learning-assisted coronary computed tomography angiography(CCTA)-derived fractional flow reserve (FFRCT) in clinical decision-making.The research in new areas,such as coronary plaque fluid dynamics study,gradually provide new tools for the diagnosis and treatment of CVD.With the continuous advancement of technology and the deepening of clinical application,it is believed that intravascular imaging will play a more important role in the future interventional treatment of CAD in the elderly patients.

Valvular heart disease (VHD) is the next epidemic in the CVD,affecting millions of people worldwide and having a major impact on healthcare systems.With the aging population,China has become a country with a high prevalence of VHD.In recent years,minimally invasive interventional therapy for VHD has developed rapidly,and new technologies and devices have emerged,providing a new treatment option for VHD patients,and also bringing new hope for more patients who cannot accept surgery.Aortic stenosis (AS) is one of the most common VHD,especially in the elderly.Transcatheter aortic valve replacement (TAVR) is a widely used interventional therapy for the treatment of AS.For asymptomatic moderate AS,the VALVENOR trial suggested that regular follow-up may help reduce the risk of death.[4]For patients with simple primary aortic regurgitation (AR),the PANTHEON trial showed that TAVR intervention remained challenging.[5]The interventional treatment of mitral regurgitation (MR) has also made remarkable progress.Transcatheter edgeto-edge repair (TEER) has been approved for highrisk degenerative and functionally severe MR.In the COAPT trial,[6]patients who received the Mitra-Clip system and medication had significantly lower the rate of hospitalization for heart failure than those who received medication alone.In addition,in the current aging society,mitral annular calcification (MAC)is becoming more common in VHD.Mitral valve replacement in patients with MAC is difficult,and the advent of transcatheter mitral valve replacement(TMVR) provides additional treatment options.The results of the MITRAL trial showed that during five years of follow-up post TMVR,[7]the symptoms of heart failure and quality of life in patients of all three groups including mitral valve-in-valve (MViV),mitral valve-in-ring (MViR),and valve-in-mitral annular calcification (ViMAC) continued to improve,and the valve function remained stable.The prevalence of tricuspid regurgitation (TR) increases with age,affecting 65-85% of adults.[8]Transcatheter tricuspid valve replacement (TTVR) and tricuspid valve TEER are potential treatments for TR.The TRISCEND trial found that patients with moderate or above TR who received TTVR experienced a sustained reduction in TR and significant improvement in hemodynamic parameters and quality of life during a oneyear follow-up.[9]The TRILUMINATE Pivotal trial,through follow-up of the patients receiving tricuspid valve TEER treatment (TriClip),showed that tricuspid valve TEER procedure was safe for patients with severe symptomatic TR,it reduced the severity of TR and was associated with improved quality of life[10].In conclusion,interventional therapy offers new treatment options for patients with VHD,especially for those who are at high risk and cannot tolerate open-heart surgery.With the continuous advancement of technology and multi-disciplinary collaboration,it is believed that interventional therapy will provide a more suitable treatment option for the elderly VHD patients in the future.

There are more procedural and periprocedural complications in the interventional treatment of elder patients with CVD.However,with the improvement of interventional devices and technologies in recent years,the success rate of coronary artery interventional therapy in elder patients with CAD has become significantly higher.The application of robot-assisted system in the field of cardiovascular intervention is more and more extensive.There are some study results strongly suggest that the use of the independently developed robot-assisted system in China for elective PCI is feasible,safe,and effective.[11]However,it is important and necessary to perform careful pre-procedure evaluation,in order to prevent various potential complications during procedure,and to closely monitor the patients post procedure.Currently clinical researches in the field of geriatric cardiovascular disease interventions are focused on understanding the physiological characteristics of elder patients and their effects.Based on these understandings,it is necessary to explore how to select and optimize interventional therapy for elderly patients,and explore customized and personalized precise interventional plan,to further provide proactive treatment strategies for cardiovascular interventional therapy in the elderly population.