Physical activity changes and clinical outcomes in elderly patients undergoing transcatheter aortic valve replacement: A systematic review_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

MAO Maoyi ¹ , CAO Tingqian ² , LUO Zeruxin ³ , CHEN Miao ⁴ ,  CHEN Qian ¹

1. Geriatrics Center, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, P. R. China;
2. Integrated Care Management Center, Outpatient Department, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
3. Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
4. Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding?author：

CHEN Qian, Email: hxqianchen@163.com

Keywords：

Elderly; transcatheter aortic valve replacement; physical activity; cardiac rehabilitation; prognosis; frailty; risk stratification; systematic review

DOI：

10.7507/1007-4848.202511074

Video：

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Objective To systematically assess postoperative changes in physical activity (PA) and their influence on clinical outcomes among elderly patients after transcatheter aortic valve replacement (TAVR), providing an evidence-based framework for risk stratification and the design of personalized cardiac rehabilitation programs. Methods A systematic search was conducted in CNKI, Wanfang, SinoMed, PubMed, Web of Science, and the Cochrane Library for relevant literature published from April 16, 2002 to January 1, 2026. Eligible studies included patients with a mean age of ≥65 years who underwent TAVR, with assessments of PA both pre- and postoperatively, and reported clinical outcomes stratified by the trajectory of PA change. Two reviewers independently performed study selection, data extraction, and quality appraisal using the Newcastle-Ottawa Scale (NOS) for cohort studies and the Cochrane Risk-of-Bias tool for randomized controlled trials. Results Four studies, all assessed as high-quality (three cohort studies with an NOS score of 8 and one randomized controlled trial with "some concerns" for risk of bias) encompassing 1 278 patients were included. The mean age was (82.2±7.3) years, and 52.0% were female. The results demonstrated a strong association between postoperative PA trajectories and clinical outcomes. Patients with persistently low or declining PA exhibited significantly higher risks of all-cause mortality, composite cardiovascular events, and rehospitalization compared to those whose PA improved or remained stable. A notable "protective effect of functional improvement" was observed: patients with low baseline PA who achieved significant postoperative improvement had prognosis comparable to those with normal baseline PA. Multivariable analyses identified advanced age, female sex, comorbidities such as chronic obstructive pulmonary disease, and cognitive impairment as independent predictors of impaired postoperative PA recovery. Conclusion Dynamic postoperative PA trajectories are a key predictor of clinical outcomes in the elderly TAVR population. This allows for risk stratification to identify a "low-benefit" high-risk cohort, for whom targeted, individualized cardiac rehabilitation interventions are crucial to optimize long-term survival and enhance quality of life.

1.	Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: a population-based study. Lancet, 2006, 368(9540): 1005-1011.
2.	Yang Y, Wang Z, Chen Z, et al. Current status and etiology of valvular heart disease in China: a population-based survey. BMC Cardiovasc Disord, 2021, 21(1): 339.
3.	Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021, 143(5): e35-e71.
4.	Praz F, Borger MA, Lanz J, et al. 2025 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2025, 46(44): 4635-4736.
5.	Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep, 1985, 100(2): 126-131.
6.	Kanamori N, Takeji Y, Taniguchi T, et al. Prognostic value of the 6-minute walk test in patients with severe aortic stenosis. Circ J, 2025, 89(9): 1566-1574.
7.	Sathananthan J, Lauck S, Piazza N, et al. Habitual physical activity in older adults undergoing TAVR: insights from the FRAILTY-AVR study. JACC Cardiovasc Interv, 2019, 12(8): 781-789.
8.	Murata M, Adachi H, Nakade T, et al. Ventilatory efficacy after transcatheter aortic valve replacement predicts mortality and heart failure events in elderly patients. Circ J, 2019, 83(10): 2034-2043.
9.	Green P, Cohen DJ, Généreux P, et al. Relation between six-minute walk test performance and outcomes after transcatheter aortic valve implantation (from the PARTNER trial). Am J Cardiol, 2013, 112(5): 700-706.
10.	Duan H, Zhang C, Zhang Q, et al. Cardiac rehabilitation for TAVR patients: mechanisms, current status, and future directions. Front Cardiovasc Med, 2025, 12: 1701764.
11.	Yamada Y, Amamoto K, Noguchi H, et al. Incidence and predictors of activities of daily living decline after transcatheter aortic valve implantation. J Anesth, 2025. PMID: 41286135. Epub ahead of print.
12.	Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ, 2021, 372: n71.
13.	Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation, 2002, 106(24): 3006-3008.
14.	Sterne JAC, Savovi? J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ, 2019, 366: l4898.
15.	Lo CK, Mertz D, Loeb M. Newcastle-Ottawa Scale: comparing reviewers' to authors' assessments. BMC Med Res Methodol, 2014, 14: 45.
16.	Goel K, O'Leary JM, Barker CM, et al. Clinical implications of physical function and resilience in patients undergoing transcatheter aortic valve replacement. J Am Heart Assoc, 2020, 9(17): e017075.
17.	Abdul-Jawad Altisent O, Puri R, Regueiro A, et al. Predictors and association with clinical outcomes of the changes in exercise capacity after transcatheter aortic valve replacement. Circulation, 2017, 136(7): 632-643.
18.	Kim DH, Afilalo J, Shi SM, et al. Evaluation of changes in functional status in the year after aortic valve replacement. JAMA Intern Med, 2019, 179(3): 383-391.
19.	Ashikaga K, Doi S, Yoneyama K, et al. Impact of perioperative change in physical function on midterm outcomes after transcatheter aortic valve implantation. Heart Vessels, 2021, 36(7): 1072-1079.
20.	Craig CL, Marshall AL, Sj?str?m M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc, 2003, 35(8): 1381-1395.
21.	Washburn RA, Smith KW, Jette AM, et al. The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol, 1993, 46(2): 153-162.
22.	Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol, 1989, 64(10): 651-654.
23.	Bull FC, Maslin TS, Armstrong T. Global physical activity questionnaire (GPAQ): nine country reliability and validity study. J Phys Act Health, 2009, 6(6): 790-804.
24.	Stewart AL, Mills KM, King AC, et al. CHAMPS physical activity questionnaire for older adults: outcomes for interventions. Med Sci Sports Exerc, 2001, 33(7): 1126-1141.
25.	Eerdekens R, Zelis J, Ter Horst H, et al. Cardiac health assessment using a wearable device before and after transcatheter aortic valve implantation: prospective study. JMIR Mhealth Uhealth, 2024, 12: e53964.
26.	American Thoracic Society. ATS/ACCP statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med, 2003, 167(2): 211-277.
27.	ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med, 2002, 166(1): 111-117.
28.	Strassmann A, Steurer-Stey C, Lana KD, et al. Population-based reference values for the 1-min sit-to-stand test. Int J Public Health, 2013, 58(6): 949-953.
29.	Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA, 2011, 305(1): 50-58.
30.	Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol, 1994, 49(2): M85-M94.
31.	Hendrikx J, Ruijs LS, Cox LG, et al. Clinical evaluation of the measurement performance of the Philips Health Watch: a within-person comparative study. JMIR Mhealth Uhealth, 2017, 5(2): e10.
32.	Fan J, Liu Q, Dai H, et al. Daily physical activity measured by wearable smartwatch for patients undergoing transcatheter aortic valve replacement: insights from the SMART TAVR study. Circ Cardiovasc Qual Outcomes, 2024, 17(1): e010066.
33.	Shen Z, Qian X, Huang C, et al. Barriers and facilitators to physical activity after transcatheter aortic valve replacement: a mixed-methods study. J Rehabil Med, 2025, 57: jrm39974.
34.	Tuttle MK, Kiaii B, Van Mieghem NM, et al. Functional status after transcatheter and surgical aortic valve replacement: 2-year analysis from the SURTAVI trial. JACC Cardiovasc Interv, 2022, 15(7): 728-738.
35.	Springhetti P, Abdoun K, Clavel MA. Sex differences in aortic stenosis: from the pathophysiology to the intervention, current challenges, and future perspectives. J Clin Med, 2024, 13(14): 4237.
36.	Haum M, Humpfer F, Steffen J, et al. Quantification of physical activity with prospective activity tracking after transfemoral aortic valve replacement. Int J Cardiol, 2023, 376: 100-107.
37.	Freitas-Ferraz AB, Rodés-Cabau J. Classical and paradoxical low-flow, low-gradient aortic stenosis: the evolving role of TAVR. JACC Cardiovasc Interv, 2019, 12(8): 764-766.
38.	Inouye SK, Studenski S, Tinetti ME, et al. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc, 2007, 55(5): 780-791.
39.	Fernández-González A, Molero-de-ávila R, Cede?o-Veloz BA, et al. Transcatheter aortic valve replacement in older adults: integrating cardiac remodeling and geriatric syndromes-a narrative review. Medicina (Kaunas), 2025, 61(9): 1515.
40.	Hiltrop N, Belmans A, Claes M, et al. Functional performance and quality of life in high-risk comorbid patients undergoing transcatheter aortic valve implantation for symptomatic aortic valve stenosis. Eur Heart J Qual Care Clin Outcomes, 2016, 2(3): 184-192.
41.	Shen Z, Geng D, Huang C, et al. Kinesiophobia and its associated factors among patients after transcatheter aortic valve replacement: a cross-sectional study based on latent profile analysis. BMC Cardiovasc Disord, 2025, 25(1): 477.
42.	Okugawa S, Shimizu H, Hayashida K, et al. Changes in the nutritional and activity status of elderly patients within 6 months of transcatheter aortic valve replacement: a mixed methods approach. Jpn J Nurs Sci, 2020, 17(2): e12305.
43.	Tarro Genta F. Cardiac rehabilitation for transcatheter aortic valve replacement. Clin Geriatr Med, 2019, 35(4): 539-548.
44.	Sperlongano S, Renon F, Bigazzi MC, et al. Transcatheter aortic valve implantation: the new challenges of cardiac rehabilitation. J Clin Med, 2021, 10(4): 810.
45.	Oz A, Tsoumas I, Lampropoulos K, et al. Cardiac rehabilitation after TAVI: a systematic review and meta-analysis. Curr Probl Cardiol, 2023, 48(3): 101531.
46.	Zhang R, Jiang H, Zhu C, et al. Effectiveness and safety of exercise training and rehabilitation in elderly patients after heart valve intervention: a systematic review and meta-analysis of randomized controlled trials. Geriatr Nurs, 2025, 62(Pt B): 259-268.
47.	Eichler S, Salzwedel A, Reibis R, et al. Multicomponent cardiac rehabilitation in patients after transcatheter aortic valve implantation: predictors of functional and psychocognitive recovery. Eur J Prev Cardiol, 2017, 24(3): 257-264.
48.	Sukul D, Albright J, Thompson MP, et al. Predictors and variation in cardiac rehabilitation participation after transcatheter aortic valve replacement. JACC Adv, 2023, 2(8): 100581.
49.	Guduguntla V, Yaser JM, Keteyian SJ, et al. Variation in cardiac rehabilitation participation during aortic valve replacement episodes of care. Circ Cardiovasc Qual Outcomes, 2022, 15(7): e009175.
50.	Ades PA, Keteyian SJ, Wright JS, et al. Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc, 2017, 92(2): 234-242.
51.	Samimi S, Hatab T, Kharsa C, et al. Meta-analysis of dedicated vs off-label transcatheter devices for native aortic regurgitation. JACC Cardiovasc Interv, 2025, 18(1): 44-57.

1. Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: a population-based study. Lancet, 2006, 368(9540): 1005-1011.
2. Yang Y, Wang Z, Chen Z, et al. Current status and etiology of valvular heart disease in China: a population-based survey. BMC Cardiovasc Disord, 2021, 21(1): 339.
3. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021, 143(5): e35-e71.
4. Praz F, Borger MA, Lanz J, et al. 2025 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2025, 46(44): 4635-4736.
5. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep, 1985, 100(2): 126-131.
6. Kanamori N, Takeji Y, Taniguchi T, et al. Prognostic value of the 6-minute walk test in patients with severe aortic stenosis. Circ J, 2025, 89(9): 1566-1574.
7. Sathananthan J, Lauck S, Piazza N, et al. Habitual physical activity in older adults undergoing TAVR: insights from the FRAILTY-AVR study. JACC Cardiovasc Interv, 2019, 12(8): 781-789.
8. Murata M, Adachi H, Nakade T, et al. Ventilatory efficacy after transcatheter aortic valve replacement predicts mortality and heart failure events in elderly patients. Circ J, 2019, 83(10): 2034-2043.
9. Green P, Cohen DJ, Généreux P, et al. Relation between six-minute walk test performance and outcomes after transcatheter aortic valve implantation (from the PARTNER trial). Am J Cardiol, 2013, 112(5): 700-706.
10. Duan H, Zhang C, Zhang Q, et al. Cardiac rehabilitation for TAVR patients: mechanisms, current status, and future directions. Front Cardiovasc Med, 2025, 12: 1701764.
11. Yamada Y, Amamoto K, Noguchi H, et al. Incidence and predictors of activities of daily living decline after transcatheter aortic valve implantation. J Anesth, 2025. PMID: 41286135. Epub ahead of print.
12. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ, 2021, 372: n71.
13. Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation, 2002, 106(24): 3006-3008.
14. Sterne JAC, Savovi? J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ, 2019, 366: l4898.
15. Lo CK, Mertz D, Loeb M. Newcastle-Ottawa Scale: comparing reviewers' to authors' assessments. BMC Med Res Methodol, 2014, 14: 45.
16. Goel K, O'Leary JM, Barker CM, et al. Clinical implications of physical function and resilience in patients undergoing transcatheter aortic valve replacement. J Am Heart Assoc, 2020, 9(17): e017075.
17. Abdul-Jawad Altisent O, Puri R, Regueiro A, et al. Predictors and association with clinical outcomes of the changes in exercise capacity after transcatheter aortic valve replacement. Circulation, 2017, 136(7): 632-643.
18. Kim DH, Afilalo J, Shi SM, et al. Evaluation of changes in functional status in the year after aortic valve replacement. JAMA Intern Med, 2019, 179(3): 383-391.
19. Ashikaga K, Doi S, Yoneyama K, et al. Impact of perioperative change in physical function on midterm outcomes after transcatheter aortic valve implantation. Heart Vessels, 2021, 36(7): 1072-1079.
20. Craig CL, Marshall AL, Sj?str?m M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc, 2003, 35(8): 1381-1395.
21. Washburn RA, Smith KW, Jette AM, et al. The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol, 1993, 46(2): 153-162.
22. Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol, 1989, 64(10): 651-654.
23. Bull FC, Maslin TS, Armstrong T. Global physical activity questionnaire (GPAQ): nine country reliability and validity study. J Phys Act Health, 2009, 6(6): 790-804.
24. Stewart AL, Mills KM, King AC, et al. CHAMPS physical activity questionnaire for older adults: outcomes for interventions. Med Sci Sports Exerc, 2001, 33(7): 1126-1141.
25. Eerdekens R, Zelis J, Ter Horst H, et al. Cardiac health assessment using a wearable device before and after transcatheter aortic valve implantation: prospective study. JMIR Mhealth Uhealth, 2024, 12: e53964.
26. American Thoracic Society. ATS/ACCP statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med, 2003, 167(2): 211-277.
27. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med, 2002, 166(1): 111-117.
28. Strassmann A, Steurer-Stey C, Lana KD, et al. Population-based reference values for the 1-min sit-to-stand test. Int J Public Health, 2013, 58(6): 949-953.
29. Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA, 2011, 305(1): 50-58.
30. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol, 1994, 49(2): M85-M94.
31. Hendrikx J, Ruijs LS, Cox LG, et al. Clinical evaluation of the measurement performance of the Philips Health Watch: a within-person comparative study. JMIR Mhealth Uhealth, 2017, 5(2): e10.
32. Fan J, Liu Q, Dai H, et al. Daily physical activity measured by wearable smartwatch for patients undergoing transcatheter aortic valve replacement: insights from the SMART TAVR study. Circ Cardiovasc Qual Outcomes, 2024, 17(1): e010066.
33. Shen Z, Qian X, Huang C, et al. Barriers and facilitators to physical activity after transcatheter aortic valve replacement: a mixed-methods study. J Rehabil Med, 2025, 57: jrm39974.
34. Tuttle MK, Kiaii B, Van Mieghem NM, et al. Functional status after transcatheter and surgical aortic valve replacement: 2-year analysis from the SURTAVI trial. JACC Cardiovasc Interv, 2022, 15(7): 728-738.
35. Springhetti P, Abdoun K, Clavel MA. Sex differences in aortic stenosis: from the pathophysiology to the intervention, current challenges, and future perspectives. J Clin Med, 2024, 13(14): 4237.
36. Haum M, Humpfer F, Steffen J, et al. Quantification of physical activity with prospective activity tracking after transfemoral aortic valve replacement. Int J Cardiol, 2023, 376: 100-107.
37. Freitas-Ferraz AB, Rodés-Cabau J. Classical and paradoxical low-flow, low-gradient aortic stenosis: the evolving role of TAVR. JACC Cardiovasc Interv, 2019, 12(8): 764-766.
38. Inouye SK, Studenski S, Tinetti ME, et al. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc, 2007, 55(5): 780-791.
39. Fernández-González A, Molero-de-ávila R, Cede?o-Veloz BA, et al. Transcatheter aortic valve replacement in older adults: integrating cardiac remodeling and geriatric syndromes-a narrative review. Medicina (Kaunas), 2025, 61(9): 1515.
40. Hiltrop N, Belmans A, Claes M, et al. Functional performance and quality of life in high-risk comorbid patients undergoing transcatheter aortic valve implantation for symptomatic aortic valve stenosis. Eur Heart J Qual Care Clin Outcomes, 2016, 2(3): 184-192.
41. Shen Z, Geng D, Huang C, et al. Kinesiophobia and its associated factors among patients after transcatheter aortic valve replacement: a cross-sectional study based on latent profile analysis. BMC Cardiovasc Disord, 2025, 25(1): 477.
42. Okugawa S, Shimizu H, Hayashida K, et al. Changes in the nutritional and activity status of elderly patients within 6 months of transcatheter aortic valve replacement: a mixed methods approach. Jpn J Nurs Sci, 2020, 17(2): e12305.
43. Tarro Genta F. Cardiac rehabilitation for transcatheter aortic valve replacement. Clin Geriatr Med, 2019, 35(4): 539-548.
44. Sperlongano S, Renon F, Bigazzi MC, et al. Transcatheter aortic valve implantation: the new challenges of cardiac rehabilitation. J Clin Med, 2021, 10(4): 810.
45. Oz A, Tsoumas I, Lampropoulos K, et al. Cardiac rehabilitation after TAVI: a systematic review and meta-analysis. Curr Probl Cardiol, 2023, 48(3): 101531.
46. Zhang R, Jiang H, Zhu C, et al. Effectiveness and safety of exercise training and rehabilitation in elderly patients after heart valve intervention: a systematic review and meta-analysis of randomized controlled trials. Geriatr Nurs, 2025, 62(Pt B): 259-268.
47. Eichler S, Salzwedel A, Reibis R, et al. Multicomponent cardiac rehabilitation in patients after transcatheter aortic valve implantation: predictors of functional and psychocognitive recovery. Eur J Prev Cardiol, 2017, 24(3): 257-264.
48. Sukul D, Albright J, Thompson MP, et al. Predictors and variation in cardiac rehabilitation participation after transcatheter aortic valve replacement. JACC Adv, 2023, 2(8): 100581.
49. Guduguntla V, Yaser JM, Keteyian SJ, et al. Variation in cardiac rehabilitation participation during aortic valve replacement episodes of care. Circ Cardiovasc Qual Outcomes, 2022, 15(7): e009175.
50. Ades PA, Keteyian SJ, Wright JS, et al. Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc, 2017, 92(2): 234-242.
51. Samimi S, Hatab T, Kharsa C, et al. Meta-analysis of dedicated vs off-label transcatheter devices for native aortic regurgitation. JACC Cardiovasc Interv, 2025, 18(1): 44-57.

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