title: Prevalence and characteristics of unoperated patients with severe aortic stenosis.
abstract: OBJECTIVE
  Although aortic valve replacement (AVR) is the preferred therapy for severe symptomatic aortic stenosis (AS), a substantial number of patients with indications for surgery do not undergo AVR. The study aim was to address, at multiple geographic locations and practice settings, the prevalence of unoperated patients with severe AS, and to explore potential barriers to intervention.
  
  
  METHODS
  The medical records at 10 centers of various size and geographic distribution were reviewed retrospectively to identify patients with clinically severe AS (echocardiography/Doppler mean gradient > or = 40 mm Hg, effective orifice area < 1.0 cm2, or an overall interpretation of severe AS; and no clinical contradiction of severe AS). Demographic, clinical and outcomes data were recorded, including referral to a cardiothoracic surgeon (CTS), performance of AVR, and rationale when no AVR was performed.
  
  
  RESULTS
  Of 952 patients who met the criteria for clinically severe AS, 497 (52%) were referred to a CTS for evaluation for AVR; subsequently, 395 patients (41%) underwent AVR and 557 (59%) were unoperated. Trends were similar across the institutions. Symptoms were present in 666 (79%) of 842 patients with available data, including 296 of 340 (87%) operated patients and 370 of 502 (74%) unoperated patients. Those patients referred to a CTS were younger, more often male, had higher aortic valve gradients, and more often were symptomatic. The dominant reasons cited for not undergoing AVR were comorbidities or high operative risk, advanced age or limited life expectancy, asymptomatic status, and patient or family refusal. The one-year survival was 94 +/- 2% for operated patients, and 69 +/- 3% for unoperated patients (66 +/- 3% for unoperated symptomatic and 78 +/- 5% for unoperated asymptomatic patients).
  
  
  CONCLUSIONS
  In this multicenter survey, only about one-half of the patients with severe AS were referred to a CTS, and only about 40% underwent AVR. Three-quarters of unoperated patients were symptomatic. Referral to a CTS appeared more likely in the setting of symptoms of angina rather than heart failure or syncope, and elevated echocardiographic gradient rather than low valve area. Many patients who likely could benefit from AVR do not undergo evaluation for the condition, and similar observations were made at multiple medical institutions.
authors.affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan 48109-5853, USA. dbach@umich.edu
authors.forename: David S
authors.initials: DS
authors.lastname: Bach
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000150:complications / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery*; D016009:Chi-Square Distribution; D015897:Comorbidity; D015150:Echocardiography, Doppler; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D015995:Prevalence; D012017:Referral and Consultation; D012111:Residence Characteristics; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D012737:Sex Factors; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D016312:Treatment Refusal; D014481:United States; D055815:Young Adult