title: Barriers to surgery in severe aortic stenosis patients with Class I indications for aortic valve replacement.
abstract: OBJECTIVE
  Despite a dismal natural history of severe aortic stenosis (AS) in patients with symptoms, there is a high non-surgical rate. The study aim was to analyze in detail the decision-making process for aortic valve replacement (AVR) that follows the diagnosis of severe AS with Class I indications, in order to identify the barriers to surgery.
  
  
  METHODS
  A total of 187 consecutive patients (105 men, 82 women; mean age 74 +/- 14 years) with severe AS, defined as aortic valve area (AVA) <1.0 cm2, was evaluated. Detailed reviews were performed for patient symptoms, and actions by physicians. The sources and reasons for non-surgical management were analyzed.
  
  
  RESULTS
  The mean AVA was 0.72 +/- 0.19 cm2 and the left ventricular ejection fraction 54 +/- 21%. A Class I indication for AVR was present in 174 patients (93%), of whom 125 (72%) were referred for AVR, which was performed in 93 cases (53%). The reasons for no AVR (n = 81) were patient refusal in 29 cases (36%), comorbidities in 28 (35%), while in 19 patients (23%) the AS was considered as 'not severe', despite being categorized as severe by ACC/AHA guidelines. The predominant factors in making the non-surgical decision were the patient or family (36%), the cardiologist (33%), and the surgeon (21%).
  
  
  CONCLUSIONS
  Class I indications for AVR are present in most patients with severe AS referred for echocardiography to a tertiary care center. Despite a Class I indication, the non-surgical rate remains high and attributable to patient reluctance, comorbidities and physician reluctance to offer AVR. It is speculated that patient discussions of the dismal natural history of severe AS and the major benefit of AVR, preferably conducted within a specialized valve clinic set-up, may help to improve the surgical rates.
authors.affiliation: Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
authors.forename: Aman
authors.initials: A
authors.lastname: Dua
authors.forename: Patricia
authors.initials: P
authors.lastname: Dang
authors.forename: Rimon
authors.initials: R
authors.lastname: Shaker
authors.forename: Padmini
authors.initials: P
authors.lastname: Varadarajan
authors.forename: Ramdas G
authors.initials: RG
authors.lastname: Pai
mesh_terms: D000368:Aged; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D003657:Decision Making; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013318:Stroke Volume / Q000502:physiology*; D016896:Treatment Outcome