Author + information
- Stephen George1,
- Sasha Prisco2,
- Umair Malik2,
- Fernando Ortiz2,
- Vignesh Palaniappan2 and
- Santiago Garcia2
The optimal timing of valve replacement among patients with asymptomatic severe aortic stenosis (AS) remains uncertain and controversial. We hypothesized that aortic valve replacement (AVR) in patients with asymptomatic severe AS is associated with improved outcomes relative to conservative management.
Observational 10-year cohort study of consecutive patients with severe AS (mean gradient 40 mmHg, aortic valve area < 1 cm2, or peak velocity 4 m/sec) that were asymptomatic at the time of echocardiography (2007-2017). Patients that were symptomatic and/or were referred for aortic valve replacement (AVR) within 6 months of the index echocardiogram were excluded. Outcomes included mortality, AVR or AS symptoms. Logistic regression analysis was performed to identify predictors of mortality. A total of 500 echocardiograms and medical records were reviewed, and 131 patients met inclusion criteria with asymptomatic severe AS.
The mean (±SD) age of the cohort was 73 (10) years and 97% were male. The median follow-up time was 10 years during which 55 (42%) patients underwent AVR and 34 (27%) died. The median time to AS symptoms was 3.6 years and the median time to AVR was 4.7 years. Patients who underwent AVR were younger (68 years, IQR: 63-77) relative to patients that were managed conservatively (76 years, IQR: 69-83, p=0.001). Otherwise no significant differences were seen in clinical or echocardiographic characteristics between groups (table). During follow-up, 27 patients (36%) died in the conservative group and 7 (13%) in the AVR group, p <0.01 (Figure). Eighteen patients (24%) died before symptom onset in the conservative management and none in the AVR group (p<0.001). Predictors of mortality in the overall cohort included performance of AVR (OR: 0.27, 95% CI: 0.08-0.88, p=0.03) and previous myocardial infarction (OR: 3.2, 95%: 0.9-11, p=0.06).
|Conservative management (n=76)||AVR (n=55)||P value|
|Age –years Median IQR||76 (69-83)||68 (63-77)||<0.01|
|Diabetes mellitus (%)||29 (40%)||18 (34%)||0.56|
|Atrial fibrillation (%)||7 (17%)||1 (4%)||0.10|
|Coronary artery disease (%)||29 (40%)||23 (43%)||0.80|
|Aortic valve area (cm2), median (IQR)||0.88 (0.80-0.94)||0.83 (0.79-0.88)||0.15|
|Peak Aortic Velocity (m/s), median (IQR)||3.6 (3.1-3.9)||3.4 (3.3-4.1)||0.77|
|Mean Gradient (mmHg), median (IQR)||30 (23-34)||30 (26-39)||0.15|
|Ejection fraction (%), mean (±SD)||57 (7)||58 (5)||0.63|
|Death||27 (36%)||7 (13%)||0.003|
One in four patients with asymptomatic severe aortic stenosis managed with a conservative approach died before symptom onset. Valve replacement is associated with improved outcomes in patients with asymptomatic aortic stenosis.
STRUCTURAL: Valvular Disease: Aortic