Risk stratification of severe aortic stenosis according to new guidelines: long term outcomes

Abstract

Background: Current ESC and ACC/AHA guidelines for the management of valvular heart disease assign a class Ia indication for aortic valve replacement (AVR) only to patients with symptomatic severe aortic valve stenosis and asymptomatic patients with depressed left ventricular ejection fraction (LVEF <50%) or positive exercise test. We examined the long-term outcomes for patients undergoing AVR for aortic stenosis over a 11-year period at our institution compared to current international guidelines for AVR. Methods: Patients who had undergone isolated AVR for severe aortic valve stenosis between January 2001 and December 2012 were selected. The population was divided into subgroups based on preoperative LVEF (< or ≥50%) and on presence/absence of symptoms (NYHA =I or ≥II, respectively). Results: We identified 607 patients with a median follow-up (FU) time of 5.75 years (IQR 3.24-8.00 years). The presence of symptoms did not have a significant impact on cardiovascular mortality (P=0.201). Patients with LVEF <50% displayed a higher long-term cardiovascular mortality rate (P=0.015). Multivariate analysis showed that preserved LVEF was a protective factor for asymptomatic patients (P=0.021), while preoperative LVEF did not affect the mortality rate in symptomatic patients (HR 0.88; 95% CI, 0.54-1.44). Correspondingly, asymptomatic patients with reduced LVEF were found to be at a higher risk of long-term mortality compared to the other groups (P=0.011). The only other independent risk factor for death was age (HR 6.46; 95% CI, 2.22-18.76). Conclusions: According to our data, current international class I indications for symptomatic patients ensure good long-term survival, while class I indications for asymptomatic patients with reduced LVEF are associated with poor long-term survival. Our results suggest that early surgery should also be considered also for asymptomatic patients with preserved LVEF, particularly in cases of very low operative risk.

Prognostic impact of main pulmonary artery to ascending aorta diameter ratio in patients with severe aortic stenosis underwent transcatheter aortic valve implantation

“…1,[3][4][5][6] Thus, accurately determining patients' preoperative risk status is essential for choosing the correct treatment option between SAVR and TAVI. [7][8][9][10][11] Considering current treatment guidelines and available literature, the most commonly used risk stratification system for appropriate treatment selection is the Society of Thoracic Surgeons (STS) risk scoring system. 12,13 This sophisticated scoring system encompasses various demographic, clinical, laboratory, echocardiographic, and hemodynamic parameters of the patients.…”

“…While SAVR is the recommended treatment for patients under 75 with low surgical mortality and perioperative morbidity risk, TAVI has emerged as the prominent treatment method for patients 75 and above, particularly those with multiple comorbidities and high surgical mortality risk 1,3–6 . Thus, accurately determining patients' preoperative risk status is essential for choosing the correct treatment option between SAVR and TAVI 7–11 …”