title: Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery?
abstract: OBJECTIVE
  To analyse decision-making in elderly patients with severe, symptomatic aortic stenosis (AS).
  
  
  RESULTS
  In the Euro Heart Survey on valvular heart disease, 216 patients aged > or =75 had severe AS (valve area < or =0.6 cm(2)/m(2) body surface area or mean gradient > or =50 mmHg) and angina or New York Heart Association class III or IV. Patient characteristics were analysed according to the decision to operate or not. A decision not to operate was taken in 72 patients (33%). In multivariable analysis, left ventricular (LV) ejection fraction [OR = 2.27, 95% CI (1.32-3.97) for ejection fraction 30-50, OR = 5.15, 95% CI (1.73-15.35) for ejection fraction < or =30 vs. >50%, P = 0.003] and age [OR = 1.84, 95% CI (1.18-2.89) for 80-85 years, OR=3.38, 95% CI (1.38-8.27) for > or =85 vs. 75-80 years, P = 0.008] were significantly associated with the decision not to operate; however, the Charlson comorbidity index was not [OR = 1.72, 95% CI (0.83-3.50), P = 0.14 for index > or =2 vs. <2]. Neurological dysfunction was the only comorbidity significantly linked with the decision not to operate.
  
  
  CONCLUSIONS
  Surgery was denied in 33% of elderly patients with severe, symptomatic AS. Older age and LV dysfunction were the most striking characteristics of patients who were denied surgery, whereas comorbidity played a less important role.
authors.affiliation: Cardiology Department, Bichat Hospital, AP-HP, Paris, France. bernard.iung@bch.aphp.fr
authors.forename: Bernard
authors.initials: B
authors.lastname: Iung
authors.forename: Agnès
authors.initials: A
authors.lastname: Cachier
authors.forename: Gabriel
authors.initials: G
authors.lastname: Baron
authors.forename: David
authors.initials: D
authors.lastname: Messika-Zeitoun
authors.forename: François
authors.initials: F
authors.lastname: Delahaye
authors.forename: Pilar
authors.initials: P
authors.lastname: Tornos
authors.forename: Christa
authors.initials: C
authors.lastname: Gohlke-Bärwolf
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
authors.forename: Philippe
authors.initials: P
authors.lastname: Ravaud
authors.forename: Alec
authors.initials: A
authors.lastname: Vahanian
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000601:surgery*; D003657:Decision Making; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011379:Prognosis; D016079:Refusal to Treat / Q000706:statistics & numerical data*; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis