Unoperated severe aortic stenosis: decision making in an adult UK-based population

Abstract

INTRODUCTIONSevere symptomatic aortic stenosis is associated with a poor prognosis, with most patients dying 2–3 years after diagnosis. We analysed the proportion of patients with severe aortic stenosis not referred for aortic valve replacement (AVR) in a UK-based population and the clinical factors contributing to this.METHODSRetrospective analysis of patients with echocardiographic evidence of severe aortic stenosis was performed at a university teaching hospital.RESULTSA total of 178 consecutive patients with severe aortic stenosis (AVA: <1cm2, mean pressure gradient: ≥40mmHg, or visually severe on echocardiography) were included in the study. Eighty-three patients did not have AVR (95% confidence interval: 39–54%). The cohort included 146 symptomatic patients (82%) and 32 (18%) who were asymptomatic. The most common reason for non-referral in symptomatic patients was ‘high operative risk’ and in asymptomatic patients ‘no symptoms’. Of the patients who did not have AVR, only 19% (n=16) were referred for a surgical opinion. None of the patients in the asymptomatic group underwent echocardiographic stress imaging. The thirty-day operative mortality rate in the AVR group was 2.3%. Symptomatic patients who underwent AVR had superior survival, even after adjusting for co-morbidities (p<0.001).CONCLUSIONSA considerable proportion of patients with severe aortic stenosis are not referred for surgery although they have a clear indication for AVR. Patients are often estimated as being too high risk or having prohibitive co-morbidities. Among asymptomatic patients, stress imaging was rarely used despite its useful role prognostically and in deciding the best time for intervention.

Regulatory Role of Sex Hormones in Cardiovascular Calcification

“…Clinically, severe stenosis can only be treated with either a mechanical or bioprosthetic valve replacement. Without surgery patient prognosis is between 2–3 years [ 25 ]. Synthetic valves characteristically have a 20-year lifespan, bringing increased mortality risks for patients requiring subsequent valve replacements [ 26 , 27 ].…”

Management of patients with severe aortic stenosis in the TAVI-era: how recent recommendations are translated into clinical practice

“…18 More recently, comorbidity has been highlighted as a reason for non-assignment of symptomatic patients to SAVR. 19 In this study, renal impairment was identified as an independent predictor of AVR denial in symptomatic patients, likely because pre-existing chronic kidney disease is strongly associated with worse outcomes following TAVI. 20 In contrast to medical management, AVR in haemodialysis patients has been shown to result in a significantly lower long-term mortality risk.…”

Restricted mean survival time of older adults with severe aortic stenosis referred for transcatheter aortic valve replacement

“…Lastly, when the primary reason for not proceeding was mild or unrelated symptoms, these patients had relatively low mortality rates during the first year of follow-up. Previous studies have described reasons for not proceeding with TAVR [6][7][8], however, these studies focused on comorbidities and symptoms and did not benefit from systematically-performed objective evaluations of frailty. This study further adds to the existing body of knowledge by connecting the various reasons for not proceeding with TAVR with projected survival.…”