title: Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis.
abstract: BACKGROUND
  Current guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS).
  
  
  OBJECTIVE
  The study sought to compare the long-term outcomes of initial AVR versus conservative strategies following the diagnosis of asymptomatic severe AS.
  
  
  METHODS
  We used data from a large multicenter registry enrolling 3,815 consecutive patients with severe AS (peak aortic jet velocity >4.0 m/s, or mean aortic pressure gradient >40 mm Hg, or aortic valve area <1.0 cm(2)) between January 2003 and December 2011. Among 1,808 asymptomatic patients, the initial AVR and conservative strategies were chosen in 291 patients, and 1,517 patients, respectively. Median follow-up was 1,361 days with 90% follow-up rate at 2 years. The propensity score-matched cohort of 582 patients (n = 291 in each group) was developed as the main analysis set for the current report.
  
  
  RESULTS
  Baseline characteristics of the propensity score-matched cohort were largely comparable, except for the slightly younger age and the greater AS severity in the initial AVR group. In the conservative group, AVR was performed in 41% of patients during follow-up. The cumulative 5-year incidences of all-cause death and heart failure hospitalization were significantly lower in the initial AVR group than in the conservative group (15.4% vs. 26.4%, p = 0.009; 3.8% vs. 19.9%, p < 0.001, respectively).
  
  
  CONCLUSIONS
  The long-term outcome of asymptomatic patients with severe AS was dismal when managed conservatively in this real-world analysis and might be substantially improved by an initial AVR strategy. (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis Registry; UMIN000012140).
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Tomohiko
authors.initials: T
authors.lastname: Taniguchi
authors.affiliation: Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Morimoto
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Hiroki
authors.initials: H
authors.lastname: Shiomi
authors.affiliation: Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan.
authors.forename: Kenji
authors.initials: K
authors.lastname: Ando
authors.affiliation: Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan.
authors.forename: Norio
authors.initials: N
authors.lastname: Kanamori
authors.affiliation: Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan.
authors.forename: Koichiro
authors.initials: K
authors.lastname: Murata
authors.affiliation: Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Kitai
authors.affiliation: Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan.
authors.forename: Yuichi
authors.initials: Y
authors.lastname: Kawase
authors.affiliation: Department of Cardiology, Tenri Hospital, Tenri, Japan.
authors.forename: Chisato
authors.initials: C
authors.lastname: Izumi
authors.affiliation: Department of Cardiology, Tenri Hospital, Tenri, Japan.
authors.forename: Makoto
authors.initials: M
authors.lastname: Miyake
authors.affiliation: Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan.
authors.forename: Hirokazu
authors.initials: H
authors.lastname: Mitsuoka
authors.affiliation: Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan.
authors.forename: Masashi
authors.initials: M
authors.lastname: Kato
authors.affiliation: Department of Cardiology, Kinki University Hospital, Osakasayama, Japan.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Hirano
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Shintaro
authors.initials: S
authors.lastname: Matsuda
authors.affiliation: Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan.
authors.forename: Kazuya
authors.initials: K
authors.lastname: Nagao
authors.affiliation: Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan.
authors.forename: Tsukasa
authors.initials: T
authors.lastname: Inada
authors.affiliation: Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan.
authors.forename: Tomoyuki
authors.initials: T
authors.lastname: Murakami
authors.affiliation: Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan.
authors.forename: Yasuyo
authors.initials: Y
authors.lastname: Takeuchi
authors.affiliation: Department of Cardiology, Nishikobe Medical Center, Kobe, Japan.
authors.forename: Keiichiro
authors.initials: K
authors.lastname: Yamane
authors.affiliation: Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan.
authors.forename: Mamoru
authors.initials: M
authors.lastname: Toyofuku
authors.affiliation: Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
authors.forename: Mitsuru
authors.initials: M
authors.lastname: Ishii
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Eri
authors.initials: E
authors.lastname: Minamino-Muta
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Takao
authors.initials: T
authors.lastname: Kato
authors.affiliation: Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan.
authors.forename: Moriaki
authors.initials: M
authors.lastname: Inoko
authors.affiliation: Department of Cardiology, Hikone Municipal Hospital, Hikone, Japan.
authors.forename: Tomoyuki
authors.initials: T
authors.lastname: Ikeda
authors.affiliation: Department of Cardiology, Kansai Electric Power Hospital, Osaka, Japan.
authors.forename: Akihiro
authors.initials: A
authors.lastname: Komasa
authors.affiliation: Department of Cardiology, Kansai Electric Power Hospital, Osaka, Japan.
authors.forename: Katsuhisa
authors.initials: K
authors.lastname: Ishii
authors.affiliation: Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan.
authors.forename: Kozo
authors.initials: K
authors.lastname: Hotta
authors.affiliation: Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan.
authors.forename: Nobuya
authors.initials: N
authors.lastname: Higashitani
authors.affiliation: Department of Cardiology, Saiseikai Noe Hospital, Osaka, Japan.
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Kato
authors.affiliation: Department of Cardiology, Shiga Medical Center for Adults, Moriyama, Japan.
authors.forename: Yasutaka
authors.initials: Y
authors.lastname: Inuzuka
authors.affiliation: Department of Cardiology, Hamamatsu Rosai Hospital, Hamamatsu, Japan.
authors.forename: Chiyo
authors.initials: C
authors.lastname: Maeda
authors.affiliation: Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan.
authors.forename: Toshikazu
authors.initials: T
authors.lastname: Jinnai
authors.affiliation: Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan.
authors.forename: Yuko
authors.initials: Y
authors.lastname: Morikami
authors.affiliation: Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Ryuzo
authors.initials: R
authors.lastname: Sakata
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan. Electronic address: taketaka@kuhp.kyoto-u.ac.jp.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Kimura
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000628:therapy*; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000592:standards*; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D057216:Propensity Score; D012042:Registries; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D057832:Watchful Waiting / Q000592:standards*
keywords: aortic valve replacement; propensity-matched; registry; risk; watchful waiting