Where are we getting it wrong? Prevalence and causes of unplanned SAVR in a UK regional cardiac centre

Surgical aortic valve replacement (SAVR) prolongs life and improves its quality in patients with severe aortic stenosis (AS). Unplanned SAVR is a failure of AS screening and follow-up programmes. We identified all elective, first, isolated SAVRs performed between 1 January and 31 December 2019 in a Welsh tertiary cardiac centre, and documented the clinical and echocardiographic variables, and reasons for unplanned SAVR. Of 140 isolated SAVR, 37 (26%) were unplanned (16 female, mean age 72.3 ± 8.4 years). Twenty had been on the SAVR waiting list and had expedited operations because of concerns about the severity of the AS (12 patients), or because of acute (four patients) or chronic (four patients) left ventricular failure (LVF). Of the 17 not on the waiting list, AS was known in seven: three had acute pulmonary oedema while under follow-up with 'moderate AS', one had been referred but developed pulmonary oedema while waiting for a surgical outpatient appointment, one refused SAVR but was subsequently admitted with acute pulmonary oedema and accepted SAVR, one was admitted directly from home because concerns about worsening AS, and one had infective endocarditis with severe aortic regurgitation. Of 10 patients with a new diagnosis of AS, five presented with LVF, four with angina and in three there was a history of syncope (p=0.003 vs. known AS; multiple symptoms). Survival, age, Canadian Cardiovascular Society (CCS) and New York Heart Association (NYHA) class, number of risk factors, peak and mean aortic valve (AV) gradients, AV area, and stroke volume index were not different between patients who had planned versus unplanned SAVR, or with known or new AS. Patients with a new diagnosis of AS had longer pre-operative wait (22.3 ± 9.3 vs. 6.0 ± 10.3 days, p<0.001). In conclusion, a quarter of SAVRs are unplanned and half are in patients without a prior diagnosis of AS. Unplanned SAVR is associated with prolonged length of hospital stay and with a history of syncope, but other conventional clinical and echocardiographic parameters do not differ between patients undergoing planned versus unplanned SAVR.