Survival after valve replacement for aortic stenosis: implications for decision making.
OBJECTIVE
Recommendations for aortic valve replacement in severe aortic stenosis are based primarily on the presence of symptoms. However, the onset of symptoms is often insidious, potentially leading to delayed intervention and suboptimal results. Identifying factors that reduce the survival of patients undergoing aortic valve replacement could lead to revised treatment guidelines and improved outcomes.


METHODS
We conducted a single-center observational clinical study of 3049 patients with aortic stenosis who underwent native aortic valve replacement with a single type of bioprosthesis. The primary end point was all-cause mortality from the date of operation. Multivariable analysis of risk factors for death was performed in the multiphase hazard function domain.


RESULTS
The presence of severe left ventricular hypertrophy at operation, which preceded symptoms in 17% of patients, was associated with decreased survival. This effect was magnified by the severity of aortic stenosis (P = .02) and use of small prostheses (P = .01). The presence of left ventricular dysfunction reduced survival (P = .0003). Although older age was a risk factor for death (P < .0001), elderly patients had survival comparable to their age, race, and sex-matched cohorts, whereas younger patients had worse than expected survival that was further diminished with insertion of a small prosthesis (P = .01).


CONCLUSIONS
To optimize survival, earlier aortic valve replacement should be considered even in asymptomatic patients before severe left ventricular hypertrophy or dysfunction develops. In younger patients, the largest possible prosthesis should be implanted to minimize residual gradient; in elderly patients, complex operations just to insert larger prostheses should be avoided.
Mihaljevic
Tomislav
T
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA. mihaljt@ccf.org
Nowicki
Edward R
ER
Rajeswaran
Jeevanantham
J
Blackstone
Eugene H
EH
Lagazzi
Luigi
L
Thomas
James
J
Lytle
Bruce W
BW
Cosgrove
Delos M
DM
D000328:Adult; D000368:Aged; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D001705:Bioprosthesis; D002315:Cardiopulmonary Bypass / Q000379:methods; D002423:Cause of Death; D015331:Cohort Studies; D003657:Decision Making; D015150:Echocardiography, Doppler; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods / Q000401:mortality*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009820:Ohio; D011183:Postoperative Complications / Q000401:mortality; D011336:Probability; D016016:Proportional Hazards Models; D011475:Prosthesis Failure; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis