Survival after valve replacement for aortic stenosis: implications for decision making.

Area of Science:

• Cardiology
• Cardiac Surgery
• Bioprosthetics

Background:

• Aortic stenosis treatment guidelines often rely on symptom onset for aortic valve replacement (AVR).
• Delayed intervention due to insidious symptom onset in severe aortic stenosis can lead to suboptimal patient outcomes.
• Identifying pre-operative factors influencing survival post-AVR is critical for refining treatment strategies.

Purpose of the Study:

• To identify pre-operative risk factors associated with mortality in patients undergoing AVR for severe aortic stenosis.
• To evaluate the impact of left ventricular hypertrophy, dysfunction, and prosthesis size on patient survival.
• To inform revised guidelines for AVR timing and prosthesis selection.

Main Methods:

• A single-center observational study included 3049 patients with severe aortic stenosis undergoing AVR with a bioprosthesis.
• The primary endpoint was all-cause mortality assessed from the date of operation.
• Multivariable analysis in the multiphase hazard function domain was used to identify risk factors for death.

Main Results:

• Severe left ventricular hypertrophy before AVR, present in 17% of patients, significantly decreased survival.
• The negative impact of hypertrophy was amplified by aortic stenosis severity and the use of small prostheses.
• Left ventricular dysfunction and the use of small prostheses in younger patients were associated with reduced survival.

Conclusions:

• Earlier AVR, even in asymptomatic patients, is recommended before severe left ventricular hypertrophy or dysfunction occurs.
• Implanting the largest feasible prosthesis in younger patients is crucial to minimize residual gradient and optimize survival.
• In elderly patients, complex procedures solely for larger prostheses should be avoided, prioritizing simpler AVR approaches.