Asymptomatic Severe Aortic Stenosis in the Elderly
What is the natural history and optimal timing of surgery in elderly patients with severe asymptomatic aortic stenosis (AS)?
A total of 103 consecutive patients >70 years of age (51 women; mean age 77 ± 5 years) with asymptomatic severe AS (peak aortic jet velocity [AV Vmax] 4.7 ± 0.6 m/s) were prospectively followed after inclusion in a heart valve clinic (HVC) program, and were scheduled for 6 monthly clinical and echocardiographic re-evaluations until criteria for surgery were reached. Patients who underwent surgery had a postoperative follow-up visit in the HVC to assess the surgical outcome. For the assessment of event-free survival, endpoints were defined as cardiac death (directly related to AS or other cardiac pathology) or guideline-based indication for aortic valve replacement (AVR). Exercise testing was used on an individual basis.
During follow-up, 91 events occurred, including an indication for AVR in 82 patients and cardiac deaths in 9 patients, respectively. Event-free survival was 73%, 43%, 23%, and 16% at 1, 2, 3, and 4 years, respectively. Physical mobility was impaired in 29% of the patients, and symptom onset was severe (New York Heart Association functional class III or IV) in 43% of those who developed symptoms. Patients with AV Vmax ≥5.0 m/s had event-free survival rates of 21% and 6% at 2 and 4 years, respectively, compared with 57% and 23% for patients with AV Vmax <5.0 m/s (p < 0.001). Seventy-one patients underwent AVR, and postoperative survival was 89% and 77% after 1 and 3 years, respectively.
In elderly patients with severe but asymptomatic AS, mild symptoms may be difficult to detect, particularly when mobility is impaired and severe symptom onset is common, warranting close clinical follow-up. A very high event rate can be expected, and cardiac deaths are not infrequent. The authors concluded that elective AV procedures may be considered in selected elderly patients at low procedural risk.
There is an increasing awareness that asymptomatic patients with severe AS are not all at low risk. In many patients, initial symptom onset is severe (and associated with poor prognosis); and, even with close clinical follow-up, the risk of death prior to intervention can be significant. Among patients with truly severe or very severe AS who are at relatively low risk for intervention, the hallmark principle of waiting for symptoms before considering surgical or transcatheter AVR probably should be reconsidered.
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