title: Unoperated severe aortic stenosis: decision making in an adult UK-based population.
abstract: BACKGROUND
  Severe symptomatic aortic stenosis is associated with a poor prognosis, with most patients dying 2-3 years after diagnosis. We analysed the proportion of patients with severe aortic stenosis not referred for aortic valve replacement (AVR) in a UK-based population and the clinical factors contributing to this.
  
  
  METHODS
  Retrospective analysis of patients with echocardiographic evidence of severe aortic stenosis was performed at a university teaching hospital.
  
  
  RESULTS
  A total of 178 consecutive patients with severe aortic stenosis (AVA: <1 cm(2), mean pressure gradient: ≥40 mmHg, or visually severe on echocardiography) were included in the study. Eighty-three patients did not have AVR (95% confidence interval: 39-54%). The cohort included 146 symptomatic patients (82%) and 32 (18%) who were asymptomatic. The most common reason for non-referral in symptomatic patients was 'high operative risk' and in asymptomatic patients 'no symptoms'. Of the patients who did not have AVR, only 19% (n=16) were referred for a surgical opinion. None of the patients in the asymptomatic group underwent echocardiographic stress imaging. The thirty-day operative mortality rate in the AVR group was 2.3%. Symptomatic patients who underwent AVR had superior survival, even after adjusting for co-morbidities (p<0.001).
  
  
  CONCLUSIONS
  A considerable proportion of patients with severe aortic stenosis are not referred for surgery although they have a clear indication for AVR. Patients are often estimated as being too high risk or having prohibitive co-morbidities. Among asymptomatic patients, stress imaging was rarely used despite its useful role prognostically and in deciding the best time for intervention.
authors.affiliation: Wessex Cardiac Centre, Southampton General Hospital, UK.
authors.forename: A A
authors.initials: AA
authors.lastname: Badran
authors.forename: H A
authors.initials: HA
authors.lastname: Vohra
authors.forename: S A
authors.initials: SA
authors.lastname: Livesey
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000401:mortality / Q000628:therapy*; D003657:Decision Making; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016019:Survival Analysis