Authors: Evan Hasson, BS - University of Miami Miller School of Medicine AND Michael Evans, MD – Ann & Robert H. Lurie Children’s Hospital of Chicago
A 42-year-old man with a history of repaired tetralogy of Fallot presents for pulmonary valve replacement due to severe pulmonic regurgitation, right ventricular dilation, and atrial arrhythmias. He reports progressively declining exercise tolerance, fatigue and reduced activity over the past year but remains independent in activities of daily living. Which of the following components of the Fried Frailty Phenotype can BEST be used in the preoperative holding area to characterize his physiologic reserve?
EXPLANATION
Advances in management of congenital heart disease have resulted in a growing population of adult congenital heart disease (ACHD) patients (0.38% of the adult population), who require surgery as they age and specialized care from pediatric cardiac anesthesiologists for those surgeries1. One of many factors complicating care of ACHD patients is the accelerated rate at which they age, secondary to hemodynamic abnormalities, cardiac operations, foreign material implantation, as well as other factors. These physiologic inputs result in a chronic inflammatory response, causing premature development of atherosclerotic disease, arrhythmias, insulin resistance, metabolic syndrome, and heart failure2.
The summation of these effects is reflected by the increased prevalence of frailty syndrome among ACHD patients. The Fried Frailty Phenotype is a useful clinical tool to quantify the degree of frailty in adult patients and has significant utility for risk-stratifying ACHD patients prior to administration of anesthesia and surgical intervention. It takes into account 5 factors: unintentional weight loss of ≥10 pounds in the last year, decreased grip strength (≤ 20th percentile for age and BMI), slow walking speed (≤ 20th percentile for age and height), self-reported exhaustion ≥ 3 days per week, and low physical activity (≤ 383 kcal/week for men and ≤ 270 kcal/week for women)3. Frailty is defined by meeting ≥ 3 criteria, pre-frailty is defined by meeting 1-2 criteria, and patients who don’t meet any criteria are characterized as “robust.”
In a large multi-center study including 814 patients with ACHD with a median age of 52 years, a frailty phenotype was found in 5.8%, while 41.9% were defined as pre-frail4. For reference, these values are comparable to other studies assessing the prevalence of frailty in non-ACHD populations with a median age of 65. Frailty and pre-frailty are associated with older age, female sex, the presence of comorbidities, and a higher physiologic class (an AHA scale was used that took into account functional status, hemodynamics, and the extent of cyanosis). The study also found that exhaustion was the most commonly reported symptom, occurring in approximately 27% of patients, and decreased grip strength was the next most common, present in approximately 16% of patients. The remaining three components each occurred in around 10% of participants.
Self-reported exhaustion is a subjective measure, but grip strength is both objective and can be easily assessed pre-operatively, even in patients that are not ambulatory. It is therefore an ideal screening tool that can alert anesthesiologists to patients who could benefit from further preoperative optimization, targeted ICU management postoperatively, or cardiac rehabilitation. If a patient does not meet the 20th percentile for grip strength, measured using a handheld dynamometer, a more thorough evaluation of the other Fried criteria should ensue. If a patient is found to be frail several weeks or months before surgery, either in a pre-anesthesia clinic visit or in a surgeon’s office, interventions such as physical therapy, nutritional optimization, and medication reconciliation can be implemented to decrease intra- and post-operative complications. If frailty is identified immediately prior to surgery, and if surgical intervention is not immediately necessary, patients may elect to postpone surgery after engaging in shared decision-making with their healthcare team to decrease undue risk until they are medically optimized. Although data relating to frailty and surgical outcomes is limited in ACHD, a systematic review and meta-analysis of over 66,000 adult cardiac surgical patients demonstrated that the presence of frailty was associated with twice the risk of adjusted mortality and three-times the risk of mid-term mortality, as well as an increased risk of sternal wound infections and prolonged hospital stay.5
A 20-meter walk is not a standardized test (answer choice B). Six-minute walk tests can be utilized as part of physiologic assessments in patients that are potential candidates for home oxygen but are not routinely utilized in the preoperative holding area. AMRAP, or "as many reps as possible," is a real term utilized in exercise, but is not a physical assessment technique used for ACHD patients preoperatively (answer choice C).
REFERENCES
1. Afilalo J, Therrien J, Pilote L, Ionescu-Ittu R, Martucci G, Marelli AJ. Geriatric congenital heart disease: burden of disease and predictors of mortality. J Am Coll Cardiol. 2011; 58(14): 1509-1515.
2. Bonanni F, Servoli C, Spaziani G, et al. Congenital Heart Disease After Mid-Age: From the "Grown-Up" to the Elderly. Diagnostics (Basel). 2025; 15(4): 481.
3. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56(3): M146-M156.
4. Daelman B, Van Bulck L, Luyckx K, et al. Frailty and Cognitive Function in Middle-Aged and Older Adults With Congenital Heart Disease. J Am Coll Cardiol. 2024; 83(12): 1149-1159.
5. Lee JA, Yangawa B, An KR et al. Frailty and pre-frailty in cardiac surgery; a systematic review and meta-analysis of 66,448 patients J Cardiothorac Surg. 2021; 16:184. https://doi.org/10.1186/s13019-021-01541-8