Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis

• Published in: Journal of the American College of Cardiology Vol. 66; no. 25; pp. 2827 - 2838
• Main Authors: Taniguchi, Tomohiko, MD, Morimoto, Takeshi, MD, MPH, Shiomi, Hiroki, MD, Ando, Kenji, MD, Kanamori, Norio, MD, Murata, Koichiro, MD, Kitai, Takeshi, MD, Kawase, Yuichi, MD, Izumi, Chisato, MD, Miyake, Makoto, MD, Mitsuoka, Hirokazu, MD, Kato, Masashi, MD, Hirano, Yutaka, MD, Matsuda, Shintaro, MD, Nagao, Kazuya, MD, Inada, Tsukasa, MD, Murakami, Tomoyuki, MD, Takeuchi, Yasuyo, MD, Yamane, Keiichiro, MD, Toyofuku, Mamoru, MD, Ishii, Mitsuru, MD, Minamino-Muta, Eri, MD, Kato, Takao, MD, Inoko, Moriaki, MD, Ikeda, Tomoyuki, MD, Komasa, Akihiro, MD, Ishii, Katsuhisa, MD, Hotta, Kozo, MD, Higashitani, Nobuya, MD, Kato, Yoshihiro, MD, Inuzuka, Yasutaka, MD, Maeda, Chiyo, MD, Jinnai, Toshikazu, MD, Morikami, Yuko, MD, Sakata, Ryuzo, MD, Kimura, Takeshi, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 29.12.2015; Elsevier Limited
• Subjects: Aged; Aged, 80 and over; aortic valve replacement; Aortic Valve Stenosis - diagnosis; Aortic Valve Stenosis - therapy; Cardiology; Cardiovascular; Clinical outcomes; Echocardiography; Female; Follow-Up Studies; Heart attacks; Heart Valve Prosthesis Implantation - standards; Hospitalization; Humans; Internal Medicine; Male; Mortality; Practice Guidelines as Topic; Propensity Score; propensity-matched; Registries; registry; risk; Risk Factors; Severity of Illness Index; Time Factors; Treatment Outcome; watchful waiting; Watchful Waiting - standards; registry; heart failure; peak aortic jet velocity; aortic valve replacement; LVEF; IQR; interquartile range; AVA; propensity-matched; left ventricular ejection fraction; pressure gradient; AS; aortic stenosis; STS; V max; PG; Society of Thoracic Surgeons; risk; aortic valve area; AVR; watchful waiting; HF; Vmax
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2015.10.001

Abstract Background Current guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS). Objectives The study sought to compare the long-term outcomes of initial AVR versus conservative strategies following the diagnosis of asymptomatic severe AS. Methods We used data from a large multicenter registry enrolling 3,815 consecutive patients with severe AS (peak aortic jet velocity >4.0 m/s, or mean aortic pressure gradient >40 mm Hg, or aortic valve area <1.0 cm2 ) between January 2003 and December 2011. Among 1,808 asymptomatic patients, the initial AVR and conservative strategies were chosen in 291 patients, and 1,517 patients, respectively. Median follow-up was 1,361 days with 90% follow-up rate at 2 years. The propensity score–matched cohort of 582 patients (n = 291 in each group) was developed as the main analysis set for the current report. Results Baseline characteristics of the propensity score–matched cohort were largely comparable, except for the slightly younger age and the greater AS severity in the initial AVR group. In the conservative group, AVR was performed in 41% of patients during follow-up. The cumulative 5-year incidences of all-cause death and heart failure hospitalization were significantly lower in the initial AVR group than in the conservative group (15.4% vs. 26.4%, p = 0.009; 3.8% vs. 19.9%, p < 0.001, respectively). Conclusions The long-term outcome of asymptomatic patients with severe AS was dismal when managed conservatively in this real-world analysis and might be substantially improved by an initial AVR strategy. (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis Registry; UMIN000012140 )