Natural History of Very Severe Aortic Stenosis

Abstract

Background-We sought to assess the outcome of asymptomatic patients with very severe aortic stenosis. Methods and Results-We prospectively followed 116 consecutive asymptomatic patients (57 women; age, 67Ϯ16 years) with very severe isolated aortic stenosis defined by a peak aortic jet velocity (AV-Vel) Ն5.0 m/s (average AV-Vel, 5.37Ϯ0.35 m/s; valve area, 0.63Ϯ0.12 cm 2 ). During a median follow-up of 41 months (interquartile range, 26 to 63 months), 96 events occurred (indication for aortic valve replacement, 90; cardiac deaths, 6). Event-free survival was 64%, 36%, 25%, 12%, and 3% at 1, 2, 3, 4, and 6 years, respectively. AV-Vel but not aortic valve area was shown to independently affect event-free survival. Patients with an AV-Vel Ն5.5 m/s had an event-free survival of 44%, 25%, 11%, and 4% at 1, 2, 3, and 4 years, respectively, compared with 76%, 43%, 33%, and 17% for patients with an AV-Vel between 5.0 and 5.5 m/s (PϽ0.0001). Six cardiac deaths occurred in previously asymptomatic patients (sudden death, 1; congestive heart failure, 4; myocardial infarction, 1). Patients with an initial AV-Vel Ն5.5 m/s had a higher likelihood (52%) of severe symptom onset (New York Heart Association or Canadian Cardiovascular Society class ϾII) than those with an AV-Vel between 5.0 and 5.5 m/s (27%; Pϭ0.03). Conclusions-Despite being asymptomatic, patients with very severe aortic stenosis have a poor prognosis with a high event rate and a risk of rapid functional deterioration. Early elective valve replacement surgery should therefore be considered in these patients. (Circulation. 2010;121:151-156.)

Impact of Mean Transaortic Pressure Gradient on Long‐Term Outcome in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

“…In this study,25 2‐year event‐free survival was 30% for patients with Vmax >4.4 m/s versus 60% for patients with Vmax <4.4 m/s. Among 622 asymptomatic patients with AS and Vmax ≥4 m/s, a Vmax ≥4.5 m/s was associated with an ≈50% increased risk of cardiac events (death or AVR)26 in a report on 116 asymptomatic patients with severe AS, a Vmax ≥5.5 m/s was associated with almost 90% increase in the risk of events (death or AVR) 27. These studies undeniably validated Vmax as an outcome marker in AS, but the cutoff for identifying patients in whom the severity of the valvular obstacle is critical remains unclear, especially for patients with no or minimal symptoms, as reflected by the different criteria used to define “very severe AS” proposed by US and European guidelines 1, 2.…”

Prognostic Value of Aortic Valve Area by Doppler Echocardiography in Patients With Severe Asymptomatic Aortic Stenosis

“…The detection of V max >5 or >5.50 m/s and a MPG ≥60 mm Hg identifies patients with very severe AS 1, 2. Recently, a peak aortic velocity >5.5 m/s was found to be associated with a high risk of events in asymptomatic patients, with rates of death or surgery of 56% at 1 year, 75% at 2 years, and 89% at 3 years 10. Given these data, current ESC guidelines consider elective AVR reasonable in cases of very severe AS, defined as V max >5.50 m/s if the surgical risk is low (class 2a recommendation) 1, 2.…”

“…In this regard, simple echocardiographic parameters such as V max have been proposed to identify patients at higher risk of adverse events. Previous reports demonstrated that asymptomatic patients with very severe AS defined by V max >5.50 m/s have a very high risk of adverse events during a short‐term follow‐up 10. Consistently, current ESC and AHA/ACC guidelines consider elective AVR reasonable in asymptomatic patients with a low surgical risk (class 2a recommendation) when V max is >5 m/s (AHA/ACC) or >5.50 m/s (ESC) or when MPG is >60 mm Hg (AHA/ACC) 1, 2.…”

Core competency review: Aortic stenosis and noncardiac surgery

“…14 Patients with asymptomatic, very severe AS, defined as peak aortic-jet velocity of 5.0 m/s or greater have an even worse prognosis with an event-free survival of 12% at 4 years and only 3% at 6 years. 15 Although short-term (1 to 5 years) prognosis for severe symptomatic AS is poor, and asymptomatic but severe AS also carries substantial risk, the major issue for the medical consultant evaluating patients prior to noncardiac surgery is the very short-term perioperative risk imposed by AS. Put simply, will the patient survive surgery and the postoperative period of rehabilitation?…”