Contemporary Management of Severe Symptomatic Aortic Stenosis

J Am Coll Cardiol. 2021 Nov 30;78(22):2131-2143. doi: 10.1016/j.jacc.2021.09.864.

Abstract

Background: There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS).

Objectives: This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey.

Methods: Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention.

Results: A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age-adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001).

Conclusions: A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians.

Keywords: aortic stenosis; decision making; guidelines; surgical aortic valve replacement; transcatheter aortic valve replacement.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Valve / diagnostic imaging
  • Aortic Valve / surgery*
  • Aortic Valve Stenosis / diagnosis
  • Aortic Valve Stenosis / epidemiology
  • Aortic Valve Stenosis / surgery*
  • Clinical Decision-Making*
  • Disease Management*
  • Echocardiography
  • Europe / epidemiology
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Morbidity / trends
  • Retrospective Studies
  • Risk Assessment / methods*
  • Risk Factors
  • Severity of Illness Index
  • Transcatheter Aortic Valve Replacement / methods*
  • Treatment Outcome