Unoperated Severe Symptomatic Aortic Stenosis

Quick Takes

  • In a multicenter, observational survey performed from 2016–2017 in the EU and UK, approximately 20% of patients with severe, symptomatic, high-gradient aortic stenosis did not undergo intervention with TAVR or SAVR.
  • The absence of intervention was associated with older age, better NYHA functional class, comorbidities, and lower mean gradient.
  • During the follow-up interval, 40% of patients who underwent intervention underwent TAVR and 60% underwent SAVR.

Study Questions:

What proportion of patients with severe, symptomatic, high-gradient aortic stenosis (AS) undergo intervention; and what clinical factors affect the decision not to intervene?


The EORP-VHD (EURObservational Research Programme Valvular Heart Disease) II study is a survey conducted between January 2016–August 2017 at 222 centers in 28 countries in the European Union (EU) and the United Kingdom (UK); patients ≥18 years of age were included if there was echocardiographic evidence of severe native valve disease or if there was prior surgical or transcatheter intervention, excluding patients with active infective endocarditis, congenital valve disease, or enrollment in a trial impacting management. The primary endpoint of analysis was the final therapeutic decision for surgical or transcatheter intervention among patients with severe, symptomatic (New York Heart Association [NYHA] functional class ≥II or angina), high-gradient (mean gradient ≥40 mm Hg) AS; and analysis of the factors associated with a decision not to intervene. Additional analysis included the mode of intervention (surgical [SAVR] vs. transcatheter aortic valve replacement [TAVR]) among all patients who underwent intervention during the study period.


Of 7,247 patients included from a 3-month interval in each center, 2,152 had severe AS without prior intervention and without concomitant moderate or severe mitral valve disease; of these, there were 1,271 patients with severe, symptomatic, high-gradient AS. 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% confidence interval [CI] 1.11-1.61, p = 0.002), NYHA functional classes I and II versus III (OR 1.63, 95% CI 1.16-2.30, p = 0.005), higher age-adjusted Charlson comorbidity index (OR 1.09 per 1-point increase, 95% CI 1.01-1.17, p = 0.03), and a lower transaortic mean gradient (OR 0.81 per 10-mm Hg decrease, 95% CI 0.71-0.92, p < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE 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 82.0-91.3 vs. 94.6%, 95% CI 92.8-95.9, p < 0.001).


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


Several observational surveys published between 2003–2011 documented that approximately one third of patients with severe, symptomatic AS did not undergo surgical intervention; typically associated with advanced age, attribution of symptoms to something other than AS, and/or perceived higher operative risk. This survey suggests that the proportion of patients with severe, symptomatic, high-gradient AS (a Class I indication for intervention) who did not undergo intervention in 2016–2017 in centers in the EU or UK had decreased to approximately one fifth, and that absent intervention still was associated with age and comorbidities. The interval change between approximately 33% versus approximately 20% of patients with a Class I indication not undergoing intervention may be attributable to better adherence to guidelines, but almost certainly is influenced by the availability of TAVR as an alternative to SAVR; it is unknown how intervention, especially the use of TAVR, may have further altered these trends in the intervening 4 years since this study was concluded. Importantly, not all patients with severe, symptomatic AS should undergo intervention; the revised survey is of interest, but it does not address appropriate use among patients who did not or those who did undergo intervention.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation

Keywords: Angina Pectoris, Aortic Valve Stenosis, Cardiac Surgical Procedures, Cardiology Interventions, Comorbidity, Diagnostic Imaging, Echocardiography, Geriatrics, Heart Failure, Heart Valve Diseases, Mitral Valve Insufficiency, Transcatheter Aortic Valve Replacement

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