Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis
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...
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Published in | Journal of the American College of Cardiology Vol. 66; no. 25; pp. 2827 - 2838 |
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Main Authors | , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |
Format | Journal Article |
Language | English |
Published |
United States
Elsevier Inc
29.12.2015
Elsevier Limited |
Subjects | |
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Abstract | 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 ) |
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AbstractList | 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 ) BACKGROUNDCurrent guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS).OBJECTIVESThe study sought to compare the long-term outcomes of initial AVR versus conservative strategies following the diagnosis of asymptomatic severe AS.METHODSWe 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 cm(2)) 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.RESULTSBaseline 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).CONCLUSIONSThe 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). Current guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS). The study sought to compare the long-term outcomes of initial AVR versus conservative strategies following the diagnosis of asymptomatic severe AS. 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 cm(2)) 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. 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). 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). Current guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS). The study sought to compare the long-term outcomes of initial AVR versus conservative strategies following the diagnosis of asymptomatic severe AS. 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. 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). 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) 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) |
Author | Kitai, Takeshi, MD Komasa, Akihiro, MD Yamane, Keiichiro, MD Taniguchi, Tomohiko, MD Ishii, Katsuhisa, MD Ishii, Mitsuru, MD Kimura, Takeshi, MD Miyake, Makoto, MD Hirano, Yutaka, MD Inuzuka, Yasutaka, MD Izumi, Chisato, MD Inoko, Moriaki, MD Higashitani, Nobuya, MD Sakata, Ryuzo, MD Kato, Takao, MD Morimoto, Takeshi, MD, MPH Shiomi, Hiroki, MD Ikeda, Tomoyuki, MD Mitsuoka, Hirokazu, MD Kawase, Yuichi, MD Hotta, Kozo, MD Murakami, Tomoyuki, MD Jinnai, Toshikazu, MD Kato, Yoshihiro, MD Ando, Kenji, MD Kanamori, Norio, MD Takeuchi, Yasuyo, MD Morikami, Yuko, MD Minamino-Muta, Eri, MD Toyofuku, Mamoru, MD Matsuda, Shintaro, MD Murata, Koichiro, MD Maeda, Chiyo, MD Nagao, Kazuya, MD Inada, Tsukasa, MD Kato, Masashi, MD |
Author_xml | – sequence: 1 fullname: Taniguchi, Tomohiko, MD – sequence: 2 fullname: Morimoto, Takeshi, MD, MPH – sequence: 3 fullname: Shiomi, Hiroki, MD – sequence: 4 fullname: Ando, Kenji, MD – sequence: 5 fullname: Kanamori, Norio, MD – sequence: 6 fullname: Murata, Koichiro, MD – sequence: 7 fullname: Kitai, Takeshi, MD – sequence: 8 fullname: Kawase, Yuichi, MD – sequence: 9 fullname: Izumi, Chisato, MD – sequence: 10 fullname: Miyake, Makoto, MD – sequence: 11 fullname: Mitsuoka, Hirokazu, MD – sequence: 12 fullname: Kato, Masashi, MD – sequence: 13 fullname: Hirano, Yutaka, MD – sequence: 14 fullname: Matsuda, Shintaro, MD – sequence: 15 fullname: Nagao, Kazuya, MD – sequence: 16 fullname: Inada, Tsukasa, MD – sequence: 17 fullname: Murakami, Tomoyuki, MD – sequence: 18 fullname: Takeuchi, Yasuyo, MD – sequence: 19 fullname: Yamane, Keiichiro, MD – sequence: 20 fullname: Toyofuku, Mamoru, MD – sequence: 21 fullname: Ishii, Mitsuru, MD – sequence: 22 fullname: Minamino-Muta, Eri, MD – sequence: 23 fullname: Kato, Takao, MD – sequence: 24 fullname: Inoko, Moriaki, MD – sequence: 25 fullname: Ikeda, Tomoyuki, MD – sequence: 26 fullname: Komasa, Akihiro, MD – sequence: 27 fullname: Ishii, Katsuhisa, MD – sequence: 28 fullname: Hotta, Kozo, MD – sequence: 29 fullname: Higashitani, Nobuya, MD – sequence: 30 fullname: Kato, Yoshihiro, MD – sequence: 31 fullname: Inuzuka, Yasutaka, MD – sequence: 32 fullname: Maeda, Chiyo, MD – sequence: 33 fullname: Jinnai, Toshikazu, MD – sequence: 34 fullname: Morikami, Yuko, MD – sequence: 35 fullname: Sakata, Ryuzo, MD – sequence: 36 fullname: Kimura, Takeshi, MD |
BackLink | https://www.ncbi.nlm.nih.gov/pubmed/26477634$$D View this record in MEDLINE/PubMed |
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Keywords | 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 |
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Snippet | Abstract Background Current guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients... Current guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic... Background Current guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with... BACKGROUNDCurrent guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe... |
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SubjectTerms | 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 |
Title | Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis |
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