Five-Year Clinical Outcome of Asymptomatic vs. Symptomatic Severe Aortic Stenosis After Aortic Valve Replacement

Shirai, Shinichi; Taniguchi, Tomohiko; Morimoto, Takeshi; Ando, Kenji; Korai, Kengo; Minakata, Kenji; Hanyu, Michiya; Yamazaki, Fumio; Koyama, Tadaaki; Komiya, Tatsuhiko; Kanamori, Norio; Murata, Katsuyuki; Kitai, Takeshi; Kawase, Yoshiaki; Izumi, Chisato; Inada, Tsukasa; Minamino‐Muta, Eri; Kato, Takao; Inoko, Moriaki; Ishii, Katsuhisa; Saito, Naritatsu; Yamanaka, Kazuhiro; Nishiwaki, Noboru; Nakajima, Hiroyuki; Sakurai, Toshihiko; Nakayama, Shogo; Sakaguchi, Genichi; Iwakura, Atsushi; Shiraga, Kotaro; Ueyama, Koji; Fujiwara, Keiichi; Miwa, Soichi; Nishizawa, Junichiro; Kitano, Mitsuru; Kitayama, Hitoshi; Sakata, Ryuzo; Kimura, Takeshi

doi:10.1253/circj.cj-16-0998

Cited by 13 publications

(5 citation statements)

References 25 publications

(12 reference statements)

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“…In the CURRENT AS registry,8 severe HF was the initial symptom during follow-up in a substantial proportion of patients in the conservative group, in whom AVR was less frequently performed than in patients without severe HF, and mortality was extremely high if AVR was not performed. Third, SAVR after symptom development might be carrying higher operative risk than SAVR during the asymptomatic phase 33. Fourth, the annual rate of sudden death during the asymptomatic phase might be higher (1.4%/year) than the rate (<1.0%/year) reported previously 10 13–15.…”

Section: Management Of Asymptomatic Patients With Severe Asmentioning

confidence: 87%

Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry

Taniguchi

Morimoto

Takeji

et al. 2020

Heart

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Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) registry was a large Japanese multicentre retrospective registry of consecutive patients with severe aortic stenosis (AS) before introduction of transcatheter aortic valve implantation. We sought to overview the data from the CURRENT AS registry to discuss the three major contemporary issues related to clinical practice in patients with severe AS: (1) under-referral/underuse of surgical aortic valve replacement (SAVR) in symptomatic patients with severe AS, (2) management of asymptomatic patients with severe AS and (3) management of patients with low-gradient severe aortic stenosis (LG-AS). First, despite the dismal prognosis of symptomatic patients with severe AS, SAVR, including those performed during follow-up, was reported to be underused. In the CURRENT AS registry, overall 53% of symptomatic patients underwent aortic valve replacement (AVR) during follow-up. Second, we reported that compared with conservative strategy, initial AVR strategy was associated with lower risk of all-cause death and heart failure hospitalisation in asymptomatic patients with severe AS. Although current recommendations for AVR are mainly dependent on the patient symptoms, some patients may not complain of any symptom because of their sedentary lifestyle. We also reported several important objective factors associated with worse clinical outcomes in asymptomatic patients with severe AS for risk stratification. Finally, initial AVR strategy was associated with better long-term clinical outcomes than conservative strategy in both patients with high-gradient AS and patients with LG-AS. The favourable effect of initial AVR strategy was also seen in patients with LG-AS with left ventricular ejection fraction of ≥50%.

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Section: Management Of Asymptomatic Patients With Severe Asmentioning

confidence: 87%

Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry

Taniguchi

Morimoto

Takeji

et al. 2020

Heart

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“…One of the reasons for the poor prognosis of symptomatic patients might be related to greater AS severity and more depressed left ventricular function in symptomatic patients. Indeed, we have recently reported that the long-term outcomes of symptomatic patients with severe AS were worse than those of asymptomatic patients when managed with initial AVR strategy 16 . Therefore, the watchful waiting strategy might be associated with poorer prognosis than early AVR strategy, even if elective AVR could be performed after watchful waiting.…”

Section: Discussionmentioning

confidence: 99%

Asymptomatic versus Symptomatic Patients with Severe Aortic Stenosis

Kanamori

Taniguchi

Morimoto

et al. 2018

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It is unknown how much different are the clinical outcomes between asymptomatic and symptomatic patients with severe aortic stenosis (AS). In the CURRENT AS registry enrolling 3,815 consecutive patients with severe AS, we compared the long-term outcomes between 1808 asymptomatic and 1215 symptomatic patients (exertional dyspnea: N = 813, syncope: N = 136, and angina: N = 266) without heart failure (HF) hospitalization. Symptomatic patients had greater AS severity, and more depressed left ventricular function than asymptomatic patients without much difference in other baseline characteristics. During a median follow-up of 3.2 years, aortic valve replacement (AVR) was performed in 62% of symptomatic patients, and 38% of asymptomatic patients. The cumulative 5-year incidences for the primary outcome measure (a composite of aortic valve-related death or HF hospitalization) was higher in symptomatic patients than in asymptomatic patients (32.3% versus 27.6%, P < 0.001). After adjusting for AVR and other variables, the greater risk of symptomatic relative to asymptomatic patients for the primary outcome measure was significant (hazard ratio 1.64, 95% confidence interval 1.41–1.96, P < 0.001). In conclusions, the excess risk of symptomatic relative to asymptomatic patients with severe AS for the aortic valve-related event was significant. However, the prevalence of AVR in symptomatic patients was not optimal.

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“…It is typically accepted from the current guidelines that the symptom development is a vital indication for intervention, whether surgical or transcatheter. A recent comprehensive study using the Japanese population recommended early intervention in selected asymptomatic subjects with AS because long-term outcomes of symptomatic patients were worse than those of asymptomatic patients 19. In fact, some groups of patients with AS processed the decompensation without any complaints at daily practice because of frailty, cognitive disorder or workload avoidance.…”

Section: Discussionmentioning

confidence: 99%

Propensity score-matched analysis of patients with severe aortic stenosis undergoing surgical aortic valve replacement

Maeda¹,

Yamashita²,

Hanyu

et al. 2019

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ObjectiveSevere aortic stenosis (AS) is one of the most serious valve conditions. Patient demography and the aetiology of AS have substantially changed in the past several decades along with a drastic improvement of surgical aortic valve replacement (SAVR) and its associated procedures. Contemporary patients with severe AS have multiple comorbidities and live much longer. We aimed to elucidate the treatment effects of SAVR on long-term outcome in propensity score (PS)-matched and the entire patient populations.MethodsWe retrospectively reviewed 570 patients with severe AS defined as an aortic valve area of 1.0 cm2 or less. Systemic differences in 39 baseline characteristics between non-SAVR and SAVR groups were adjusted using PS matching method. The endpoints included all-cause mortality and cardiovascular events that included heart failure, non-fatal stroke, syncope and acute coronary syndrome.ResultsOverall, 55% of the entire population (mean age 78 years; males 41%) were symptomatic. During 3.9 years of the median follow-up, 210 (36%) patients underwent SAVR and 231 (41%) died. Cumulative incidences of mortality and both mortality and cardiovascular events were significantly higher in the non-SAVR group than in the other group (p<0.001, each). Among 101 PS-matched pairs, SAVR correlated with a lower mortality risk (HR 0.35; 95% CI 0.21 to 0.59; p<0.001)) and mortality and cardiovascular events combined (HR 0.62; 95% CI 0.42 to 0.92; p=0.02). However, survival difference between both groups was markedly smaller among asymptomatic patients in the subgroup of matched patients.ConclusionPatients with AS undergoing SAVR exhibit a lower incidence of all-cause mortality and major cardiovascular events than those not undergoing surgical interventions, even after the baseline characteristics are balanced by the PS matching. The correlation between SAVR and survival from cardiovascular events is less evident among asymptomatic patients.

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Five-Year Clinical Outcome of Asymptomatic vs. Symptomatic Severe Aortic Stenosis After Aortic Valve Replacement

Abstract: Background: 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).

Cited by 13 publications

References 25 publications

Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry

Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry

Asymptomatic versus Symptomatic Patients with Severe Aortic Stenosis

Propensity score-matched analysis of patients with severe aortic stenosis undergoing surgical aortic valve replacement

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