Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis

Taniguchi, Tomohiko; Morimoto, Takeshi; Shiomi, Hiroki; Ando, Kenji; Kanamori, Norio; Murata, Katsuyuki; Kitai, Takeshi; Kawase, Yoshiaki; Izumi, Chisato; Miyake, Makoto; Mitsuoka, Hirokazu; Kato, Masashi; Hirano, Yutaka; Matsuda, Shintaro; Nagao, Keisuke; Inada, Tsukasa; Murakami, Tomoyuki; Takeuchi, Yasuyo; Yamane, Keiichiro; Toyofuku, Mamoru; Ishii, Mitsuru; Minamino‐Muta, Eri; Kato, Takao; Inoko, Moriaki; Ikeda, Tomoyuki; Komasa, Akihiro; Ishii, Katsuhisa; Hotta, Kozo; Higashitani, Nobuya; Kato, Yoshihiro; Inuzuka, Yasutaka; Maeda, Chiyo; Jinnai, Toshikazu; Morikami, Yasuhiro; Sakata, Ryuzo; Kimura, Takeshi; Investigators, Current As Registry

doi:10.1016/j.jacc.2015.10.001

Cited by 246 publications

(176 citation statements)

References 21 publications

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“…Because improved surgical techniques have led to lower operative mortality and morbidity rates, earlier intervention has been increasingly advocated 3, 4, 5. Another recent report revealed that an initial SAVR strategy in patients with asymptomatic severe AS was associated with a lower risk for all‐cause mortality compared with a conservative watchful waiting approach 6. Current guidelines recommend that patients with significantly calcified valves, rapid hemodynamic progression, and a positive exercise test are likely to benefit from early elective surgery 1, 2.…”

Section: Discussionmentioning

confidence: 99%

“…According to recent Western guidelines, early invasive therapy is strongly recommended for symptomatic patients with severe AS because of their poor prognosis 1, 2. Based on the current low periprocedural mortality rates for isolated surgical aortic valve replacement (SAVR), earlier surgery for asymptomatic patients with severe AS has been increasingly advocated 3, 4, 5, 6. These studies suggest that early treatment of severe AS may improve the patient's prognosis.…”

Section: Introductionmentioning

confidence: 99%

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Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Shimura

Yamamoto

Kano

et al. 2018

JAHA

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BackgroundAlthough transcatheter aortic valve replacement (TAVR) is the least invasive treatment for patients with symptomatic aortic stenosis, some patients hesitate to undergo the procedure. We investigated the clinical impact of treatment delay after patient refusal of TAVR.Methods and ResultsWe used the Japanese OCEAN (Optimized Catheter valvular intervention) regsitry data of 1542 patients who underwent TAVR. Refusal was defined as at least 1 refusal of TAVR at the time of informed consent. Patients were separated into 2 groups: refusal (28/1542, 1.8%) and non‐refusal (1514/1542, 98.2%). We compared the baseline characteristics, procedural outcomes, and mortality rates between the groups. Additionally, data on reasons for refusal and those leading to eventually undergoing TAVR were collected. Age, surgical risk scores, and frailty were higher in the refusal group than in the non‐refusal group (P<0.05 for all). Periprocedural complications did not differ between groups, whereas 30‐day and cumulative 1‐year mortality were significantly higher in the refusal group than in the non‐refusal group (7.1% versus 1.3%, P=0.008 and 28.8% versus 10.3%, P=0.010, respectively). Multivariate Cox regression analysis revealed that TAVR refusal was an independent predictor of increased midterm mortality (hazard ratio: 3.37; 95% confidence interval: 1.52–7.48; P=0.003). The most common reason for refusal was fear (13/28, 46.4%), and the most common reason for changing their mind was worsening heart failure (21/28, 75.0%). All patients in the refusal group decided to undergo TAVR within 20 months (median: 5.5 months).ConclusionsRefusing TAVR even once led to poorer prognosis; therefore, this fact should be clearly discussed when obtaining informed consent.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Shimura

Yamamoto

Kano

et al. 2018

JAHA

View full text Add to dashboard Cite

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“…On the one hand, as reported,21, 22, 23 the 2‐year risk of cardiac events (onset of symptoms, AVR, or mortality) in asymptomatic patients with hemodynamically significant AS is high, whereas the risk of sudden death is low. Conversely, AVR should ideally be performed before the onset of irreversible left heart remodeling that reduces the long‐term benefit of surgery 24. Therefore, the decision to operate asymptomatic individuals with severe AS must be based on careful assessment of the benefit‐risk balance.…”

Section: Discussionmentioning

confidence: 99%

Impact of Mean Transaortic Pressure Gradient on Long‐Term Outcome in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Bohbot

Kowalski

Ruşinaru

et al. 2017

JAHA

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BackgroundMean transaortic pressure gradient (MTPG) has never been validated as a predictor of mortality in patients with severe aortic stenosis. We sought to determine the value of MTPG to predict mortality in a large prospective cohort of severe aortic stenosis patients with preserved left ventricular ejection fraction and to investigate the cutoff of 60 mm Hg, proposed in American guidelines.Methods and ResultsA total of 1143 patients with severe aortic stenosis defined by aortic valve area ≤1 cm2 and MTPG ≥40 mm Hg were included. The population was divided into 3 groups according to MTPG: between 40 and 49 mm Hg, between 50 and 59 mm Hg, and ≥60 mm Hg. The end point was all‐cause mortality. MTPG was ≥60 mm Hg in 392 patients. Patients with MTPG ≥60 mm Hg had a significantly increase risk of mortality compared with patients with MTPG <60 mm Hg (hazard ratio [HR]=1.62 [1.27–2.05] P<0.001), even for the subgroup of asymptomatic or minimally symptomatic patients (HR=1.56 [1.04–2.34] P=0.032). After adjustment for established outcome predictors, patients with MTPG ≥60 mm Hg had a significantly higher risk of mortality than patients with MTPG <60 mm Hg (HR=1.71 [1.33–2.20] P<0.001), even after adjusting for surgery as a time‐dependent variable (HR=1.71 [1.43–2.11] P<0.001). Similar results were observed for the subgroup of asymptomatic or minimally symptomatic patients (HR=1.70 [1.10–2.32] P=0.018 and HR=1.68 [1.20–2.36] P=0.003, respectively).ConclusionsThis study shows the negative prognostic impact of high MTPG (≥60 mm Hg), on long‐term outcome of patients with severe aortic stenosis with preserved left ventricular ejection fraction, irrespective of symptoms.

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“…It has been suggested, however, that when using a “wait for symptoms” strategy, some patients may be operated too late in the course of the disease, at a stage at which myocardial impairment is, at least in part, irreversible 7, 8. Recent studies suggested that the outcome of asymptomatic patients with severe AS was improved by surgical management compared with conservative management 9, 23. These findings have prompted several investigators to recommend early AVR in asymptomatic patients with severe AS6; however, when performing an AVR, the native valve disease is generally traded for prosthetic valve disease because prosthetic valves are associated with complications that may affect patients’ outcome.…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, a “wait for symptoms” strategy is proposed in clinical practice because the surgical risk exceeds the spontaneous risk in most patients with severe asymptomatic AS 6. In contrast, it has been advocated that some patients with severe asymptomatic AS may be operated too late in the course of the disease, at a stage at which myocardial impairment is, at least in part, irreversible7, 8 and thus resulting in a higher risk of mortality and heart failure 9. In this regard, simple echocardiographic parameters such as V max have been proposed to identify patients at higher risk of adverse events.…”

Section: Introductionmentioning

confidence: 99%

Prognostic Value of Aortic Valve Area by Doppler Echocardiography in Patients With Severe Asymptomatic Aortic Stenosis

Maréchaux

Ringlé

Ruşinaru

et al. 2016

JAHA

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BackgroundThe aim of this study was to evaluate the relationship between aortic valve area (AVA) obtained by Doppler echocardiography and outcome in patients with severe asymptomatic aortic stenosis and to define a specific threshold of AVA for identifying asymptomatic patients at very high risk based on their clinical outcome.Methods and ResultsWe included 199 patients with asymptomatic severe aortic stenosis (AVA ≤1.0 cm2). The risk of events (death or need for aortic valve replacement) increased linearly on the scale of log hazard with decreased AVA (adjusted hazard ratio 1.17; 95% CI 1.06–1.29 per 0.1 cm2 AVA decrement; P=0.002). Event‐free survival at 12, 24, and 48 months was 63±6%, 51±6%, and 34±6%, respectively, for AVA 0.8 to 1 cm2; 49±6%, 36±6%, and 26±6%, respectively, for AVA 0.6 to 0.8 cm2; and 33±8%, 20±7%, and 11±5%, respectively, for AVA ≤0.6 cm2 (P trend=0.002). Patients with AVA ≤0.6 cm2 had a significantly increased risk of events compared with patients with AVA 0.8 to 1 cm2 (adjusted hazard ratio 2.22; 95% CI 1.41–3.52; P=0.001), whereas patients with AVA 0.6 to 0.8 cm2 had an increased risk of events compared with those with AVA 0.8 to 1 cm2, but the difference was not statistically significant (adjusted hazard ratio 1.38; 95% CI 0.93–2.05; P=0.11). After adjustment for covariates and aortic valve replacement as a time‐dependent variable, patients with AVA ≤0.6 cm2 had a significantly greater risk of all‐cause mortality than patients with AVA >0.6 cm2 (hazard ratio 3.39; 95% CI 1.80–6.40; P<0.0001).ConclusionsPatients with severe asymptomatic aortic stenosis and AVA ≤0.6 cm2 displayed an important increase in the risk of adverse events during short‐term follow‐up. Further studies are needed to determine whether elective aortic valve replacement improves outcome in this high‐risk subgroup of patients.

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Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis

Cited by 246 publications

References 21 publications

Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Impact of Mean Transaortic Pressure Gradient on Long‐Term Outcome in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Prognostic Value of Aortic Valve Area by Doppler Echocardiography in Patients With Severe Asymptomatic Aortic Stenosis

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