Perioperative Risk of Major Non-Cardiac Surgery in Patients With Severe Aortic Stenosis: A Reappraisal in Contemporary Practice

Study Questions:

What is the perioperative mortality of patients with severe aortic stenosis?

Methods:

This was a retrospective study of patients with echocardiographic evidence of severe aortic stenosis undergoing intermediate- or high-risk surgical interventions at a tertiary medical center between 2000 and 2010. Controls were matched for age, sex, and year of surgery. Outcomes of interest were 30-day mortality rate, major adverse cardiovascular events (MACE), and 1-year survival.

Results:

There were 256 patients with severe aortic stenosis, matched to 256 controls. There was a nonstatistically significant increase in 30-day mortality rates among patients with severe aortic stenosis (5.9% vs. 3.1%, p = 0.13). Patients with severe aortic stenosis did experience more MACE (18.8% vs. 10.5%, p = 0.01). This was primarily due to new or worsening heart failure. Patients with symptomatic severe aortic stenosis had significantly higher MACE at 30 days compared to controls (28.3% vs. 8.5%, p < 0.001). In patients with symptomatic severe aortic stenosis, there was also a nonstatistically significant trend toward 30-day mortality (9.4% vs. 3.8%, p = 0.097). When emergency surgery was excluded, perioperative mortality for routine surgery was <5% in both control patients and those with severe aortic stenosis.

Conclusions:

The authors concluded that although associated with increased MACE, severe aortic stenosis is not associated with significantly increased perioperative mortality.

Perspective:

This is an important study that adds to our understanding of the risk of noncardiac surgery among patients with severe aortic stenosis in contemporary practice. The perioperative mortality in patients with severe aortic stenosis in this contemporary study is significantly lower than that reported by older studies. Furthermore, the authors draw attention to the risk of noncardiac surgery in symptomatic patients with severe aortic stenosis. Such findings would support current American and European guidelines, which advise against elective surgery in symptomatic patients before addressing severe aortic stenosis through surgical or percutaneous interventions. On the other hand, and as the authors write, postponing elective intervention until severe aortic stenosis is addressed may be ‘overly conservative’ in select asymptomatic patients.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: omega-Chloroacetophenone, Leucomycins, Heart Failure, Cardiovascular Diseases, Cardiac Surgical Procedures, United States


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