Clinical Outcomes in Non-Surgically Managed Patients With Very Severe Versus Severe Aortic Stenosis

Study Questions:

What are the clinical outcomes of patients with severe versus very severe aortic stenosis (AS)?

Methods:

In a single-center, retrospective cohort study, 108 conservatively treated patients with severe AS (maximal jet velocity ≥4.0 m/s, mean aortic pressure gradient [MPG] ≥40 mm Hg, or aortic valve area [AVA] <1.0 cm2) and 58 patients with very severe AS (maximal jet velocity ≥5.0 m/s, MPG ≥50 mm Hg, or AVA <0.6 cm2) were compared. Clinical outcomes (all-cause mortality and valve-related events [defined by a composite of cardiac death and hospitalization because of heart failure]) were assessed.

Results:

Mean follow-up was 5.5 ± 3.1 years. A total of 56 patients (52%) with severe AS and 20 patients (34%) with very severe AS were asymptomatic. At 3 years, very severe AS patients had poorer survival and valve-related event-free survival than did severe AS patients (77% vs. 88%, p < 0.01; 75% vs. 88%, p < 0.001, respectively). In addition, the 3-year survival and valve-related event-free survival of asymptomatic very severe AS were comparable with symptomatic severe AS, but they were significantly worse than asymptomatic severe AS patients (p < 0.01 and p < 0.001, respectively).

Conclusions:

The authors concluded that surgery should always be considered in patients with very severe AS regardless of symptoms, and particular attention needs to be paid to their extremely poor outcomes.

Perspective:

The dogma that all patients with severe AS are at low risk as long as they remain asymptomatic clearly needs to be reassessed. Some patients remain asymptomatic because of little if any daily exertion, others remain asymptomatic because they don’t know what it might feel like to be 80 years old and not have severe AS, and others simply might not admit to symptoms. This study does a nice job of demonstrating that not all ‘severe’ AS is the same. Patients with very severe AS (in this study defined as jet velocity ≥5.0 m/s, MPG ≥50 mm Hg, or AVA <0.6 cm2) were found to be at high risk for morbid and mortal valve-related events. In patients with severe AS , lack of symptoms should not be taken as an over-riding reason to discount consideration for surgical intervention.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Risk, Follow-Up Studies, Morbidity, Arterial Pressure, Heart Failure, Cardiovascular Diseases


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