title: Incidence, determinants, and prognostic impact of operative refusal or denial in octogenarians with severe aortic stenosis.
abstract: BACKGROUND
  Aortic stenosis (AS) is a common valve disease in octogenarians. Previous studies have shown that aortic valve replacement (AVR) is frequently not performed in these patients. This study investigated the incidence, determinants, and prognostic impact of AVR refusal or denial in these patients.
  
  
  METHODS
  Between 2000 and 2007, 163 octogenarians (mean age, 84 ± 3 years) with severe AS and an indication for operation according to guidelines were prospectively included in an echocardiographic registry. Among these, 97 underwent AVR, and 66 were treated conservatively.
  
  
  RESULTS
  Logistic regression analysis identified older age, a lower transaortic pressure gradient, a larger aortic valve area, and the presence of diabetes as independent predictors of AVR refusal or denial. Patients who underwent AVR had a 30-day mortality of 9%. Overall 5-year survival was 66% in AVR patients vs 31% in those treated conservatively (log rank p < 0.001 vs AVR). After adjustment for the propensity score, patients undergoing AVR still had a better outcome than conservatively treated patients (hazard ratio, 0.56; 95% confidence interval, 0.29 to 0.91; p = 0.022). In addition to the therapeutic decision, Cox regression analysis also identified low body weight, New York Heart Association class III/IV, and the logistic European System for Cardiac Operative Risk Evaluation as independent predictors of outcome in the overall series.
  
  
  CONCLUSIONS
  About 40% of octogenarians with severe AS and a definite indication for operation either refuse or are denied AVR. AVR refusal or denial has a profound impact on long-term prognosis, resulting in a twofold excess mortality, even after adjustment for the propensity score.
authors.affiliation: Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
authors.forename: Sophie
authors.initials: S
authors.lastname: Piérard
authors.forename: Stéphanie
authors.initials: S
authors.lastname: Seldrum
authors.forename: Christophe
authors.initials: C
authors.lastname: de Meester
authors.forename: Agnès
authors.initials: A
authors.lastname: Pasquet
authors.forename: Bernhard
authors.initials: B
authors.lastname: Gerber
authors.forename: David
authors.initials: D
authors.lastname: Vancraeynest
authors.forename: Gébrine
authors.initials: G
authors.lastname: El Khoury
authors.forename: Philippe
authors.initials: P
authors.lastname: Noirhomme
authors.forename: Annie
authors.initials: A
authors.lastname: Robert
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Vanoverschelde
mesh_terms: D000367:Age Factors; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000601:surgery*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D011379:Prognosis; D011446:Prospective Studies; D016079:Refusal to Treat; D012720:Severity of Illness Index