Reasons for Choosing Conservative Management in Symptomatic Patients With Severe Aortic Stenosis ― Observations From the CURRENT AS Registry ― (original) (raw)
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Circulation: Cardiovascular Interventions, 2018
Background: Although aortic valve replacement (AVR) can be lifesaving, many patients with symptomatic aortic stenosis do not undergo appropriate therapy. This study sought to examine the characteristics, outcomes, and reasons for not pursuing AVR in a contemporary cohort. Methods and Results: We examined 548 patients with severe, symptomatic aortic stenosis not treated with AVR through March 2017. Patients were grouped according to AVR appropriateness based on the presence of medical futility. Demographics, rationale for no AVR therapy, and outcomes were assessed. There were 359 (65.5%) potentially appropriate candidates for AVR and 189 (34.5%) others patients with futility. Among potentially appropriate patients, 62.1% had severe symptoms, 74.4% had not been referred for AVR, and 40.1% were low risk. Patient refusal was common (54.6%), with incorrect symptom assignment or aortic stenosis severity classification accounting for nearly all other explanations. Compared with patients wi...
Therapeutic decisions for patients with symptomatic severe aortic stenosis: room for improvement?
European Journal of Cardio-Thoracic Surgery, 2009
Objective: Symptomatic severe aortic stenosis is an indication for aortic valve replacement. Some patients are denied intervention. This study provides insight into the proportion of conservatively treated patients and into the reasons why conservative treatment is chosen. Methods: Of a patient cohort presenting with severe aortic stenosis between 2004 and 2007, medical records were retrospectively analyzed. Only symptomatic patients (n = 179) were included. We studied their characteristics, treatment decisions, and survival. Results: Mean age was 71 years, 50% were male. During follow-up (mean 17 months, 99% complete) 76 (42%) patients were scheduled for surgical treatment (63 conventional valve replacement, 10 transcatheter, 1 heart transplantation, 2 waiting list) versus 101 (56%) who received medical treatment. Reasons for medical treatment were: perceived high operative risk (34%), symptoms regarded mild (19%), stenosis perceived non-severe (14%), and patient preference (9%). In 5% the decision was pending at the time of the analysis and in 20% the reason was other/unclear. Mean age of the surgical group was 68 years versus 73 years for medically treated patients (p = 0.004). Predicted mortality (EuroSCORE) was 7.8% versus 11.3% (p = 0.006). During follow-up 12 patients died in the surgical group (no 30-day operative mortality), versus 28 in the medical group. Two-year survival was 90% versus 69%. Conclusions: A large proportion (56%) of symptomatic patients does not undergo aortic valve replacement. Often operative risk is estimated (too) high or hemodynamic severity and symptomatic status are misclassified. Interdisciplinary team discussions between cardiologists and surgeons should be encouraged to optimize patient selection for surgery.
Circulation: Cardiovascular Quality and Outcomes, 2009
Background— Some patients with severe symptomatic aortic stenosis (AS) do not undergo aortic valve replacement (AVR) despite demonstrated symptomatic and survival advantages and despite unequivocal guideline recommendations for surgical evaluation. Methods and Results— In 3 large tertiary care institutions (university, Veterans Affairs, and private practice) in Washtenaw County, Mich, patients were identified with unrefuted echocardiography/Doppler evidence of severe AS during calendar year 2005. Medical records were retrospectively reviewed for symptoms, referral for AVR, calculated operative risk for AVR, and rationale as to why patients did not undergo valve replacement. Of 369 patients with severe AS, 191 (52%) did not undergo AVR. Of these, 126 (66%, 34% of total) had symptoms consistent with AS. The most common reasons cited for absent intervention were comorbidities with high operative risk (61 patients [48%]), patent refusal (24 patients [19%]), and symptoms unrelated to AS ...
Decision-making and outcomes in severe symptomatic aortic stenosis
The Journal of heart valve disease
Background and aim of the study: Aortic stenosis (AS) remains the most common valvular disease of the elderly in the United States. Though valve replacement has proven effective among older adults, decision-making regarding surgery is difficult for these patients and their physicians. Herein, the clinical outcomes and decision-making process for elderly patients with severe symptomatic AS was assessed. Methods: A retrospective cohort study of patients aged ≥60 years with severe AS was conducted at two large urban teaching hospitals. Severe AS was defined by a mean valve gradient ≥50 mmHg or valve area <0.8 cm 2 by echocardiogram, and associated symptoms (angina, congestive heart failure, dyspnea, fatigue, or exercise intolerance). Demographic and clinical data and information about decision-making were obtained from inpatient and outpatient medical records. Results: Of the 124 patients studied, 49 (39.5%) had aortic valve replacement (AVR) surgery. In a logistic regression analysis adjusting for gender, comorbidi-ty and baseline functional status, those patients aged <80 years were significantly more likely to have surgery than older patients. Surgery was associated with a large reduction in mortality in all age groups. At one-year follow up, 87.8% of all patients (87.5% of those aged ≥80 years) who had undergone surgery were alive, while only 54.7% (49.1% of those aged ≥80 years) who did not receive surgery were alive. Postoperative complications were similar among older and younger elderly patients. Comorbidity and age were the most common reasons for not offering elderly patients valve replacement.
Circulation, 2022
Background: Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated. Method: The Aortic Valve replAcemenT versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR) trial is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm2 with aortic jet velocity >4 m/s or a mean trans-aortic gradient ≥40 mm Hg), and with normal LV function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite endpoint of all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure, as compared to a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries. Results: Between June 2015 and September 2020, 157 patients (mean age 67 years, 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite endpoint than those in the conservative arm (HR 0.46, 95% CI 0.23-0.90, p=0.02). There was no statistical difference in secondary endpoints, including all-cause mortality, first heart failure hospitalizations, major bleeding or thromboembolic complications, but trends were consistent with the primary outcome. Conclusion: In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms.
Circulation journal : official journal of the Japanese Circulation Society, 2017
There is discordance regarding the effect of symptom status before aortic valve replacement (AVR) on long-term outcome after AVR in severe aortic stenosis (AS).Methods and Results:The CURRENT AS registry is a multicenter retrospective registry enrolling 3,815 consecutive patients with severe AS. Among 1,196 patients managed with the initial AVR strategy, long-term clinical outcomes were compared between the symptomatic patients (n=905), and asymptomatic patients (n=291). Median follow-up interval was 1337 days with a 91% follow-up rate at 2 years. AVR was performed in 886 patients (98%) in the symptomatic group and in 287 patients (99%) in the asymptomatic group. Symptomatic patients were older and more often had comorbidities than asymptomatic patients with similar echocardiographic AS severity. The cumulative 5-year incidences of all-cause death and heart failure (HF) hospitalization were significantly higher in symptomatic patients than in asymptomatic patients (25.6% vs. 15.4%, ...
QJM, 2008
Background: Aortic valve replacement (AVR) can be performed safely in selected elderly patients with aortic stenosis (AS). However, the survival benefits of AVR over conservative treatment have not been convincingly demonstrated in AS patients aged above 80. Aim: To investigate the outcomes of patients aged 80 and over with symptomatic, severe AS and by analyzing the effects of patient's choice in either agreeing or refusing to undergo AVR, determine the survival benefits afforded by AVR. Design: Cohort study. Methods: Subjects aged 80 and over with severe symptomatic AS, diagnosed between 2001 and 2006 were segregated into three groups: subjects who underwent AVR (Group A); patients who were fit for AVR but declined surgery due to personal choice (Group B) and those who were not fit for surgery and were managed conservatively (Group C). Follow-up was conducted by out-patient attendances, review of
International Journal of Cardiology, 2012
Objectives: Aortic valve replacement (AVR) is recommended in patients with symptomatic aortic stenosis (AS). However a large number of elderly patients remain untreated because of a high operative risk. The aim of this study was to assess the risk profile of a group of AS patients, evaluating the prevalence of comorbidities and associated cardiac diseases and their impact on therapeutic decisions. Methods: Two-hundred forty consecutive AS patients underwent complete clinical evaluation, in order to define the stenosis severity, the prevalence of several associated cardiac conditions and comorbidities. Furthermore, the treatment choices based on this approach were recorded. Results: Mean age was 78.6 ± 8.93 years, 75.5% was ≥ 75 years old, 60% females; 226 patients (94.2%) had symptoms and 54.2% was in NYHA classes III-IV. Valve area b 1 cm 2 was detected in 81.6% of patients. Both comorbidities and associated cardiac diseases were common; particularly, renal dysfunction was detected by estimated glomerular filtration rate in 52.7%, chronic obstructive lung disease in 25.4%, cerebrovascular/ peripheral artery disease in 30.8% and 11.6%, respectively, diabetes in 30%, malignancies (current or previous) in 26.6% of patients. Among associated cardiac diseases, coronary artery disease was detected in 43.7%, LV systolic dysfunction in 28.7%, pulmonary hypertension in 67%, at least moderate mitral regurgitation in 32.5% and porcelain aorta in 7.5% of patients. Fourteen asymptomatic patients (pts) (5.9%) remained in follow-up, 77 (32%) underwent surgical AVR, 64 (26.7%) underwent transcatheter valve implantation, 28 (11.6%) underwent balloon valvuloplasty and 57 (23.8%), despite symptoms, remained on medical therapy alone. Conclusions: Comorbidities and coexisting cardiac diseases are very common in AS and may strongly influence the decision-making process.