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

Ann R Coll Surg Engl. 2012 Sep;94(6):416-21. doi: 10.1308/003588412X13171221591817.


Introduction: Severe 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.

Methods: Retrospective analysis of patients with echocardiographic evidence of severe aortic stenosis was performed at a university teaching hospital.

Results: A total of 178 consecutive patients with severe aortic stenosis (AVA: <1 cm(2), mean pressure gradient: ≥40 mmHg, 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).

Conclusions: A 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.

MeSH terms

  • Age Factors
  • Aged
  • Aged, 80 and over
  • Aortic Valve Stenosis / mortality
  • Aortic Valve Stenosis / therapy*
  • Decision Making*
  • England / epidemiology
  • Female
  • Humans
  • Male
  • Middle Aged
  • Referral and Consultation / statistics & numerical data*
  • Retrospective Studies
  • Survival Analysis