Differential Effect of Early Intervention for Moderate Aortic Stenosis by Extravalvular Damage

It is unknown whether early intervention may be beneficial for patients with moderate aortic stenosis (AS) and if so, for whom. We compared the effect of early intervention with conservative treatment in moderate AS patients according to extravalvular cardiac damage.

This multicenter retrospective cohort study included consecutive patients with moderate AS (aortic valve area, 1.0-1.5 cm², peak velocity 3-4 m/s, or mean pressure gradient 20-40 mm Hg, with any parameter beyond these limits defined as severe AS) from 2008 to 2020. Patients were categorized by extravalvular cardiac damage: stage 0 (none), stage 1 (left ventricle), stage 2 (left atrial/mitral valve), stage 3 (pulmonary hypertension/tricuspid valve), and stage 4 (right ventricle), with low-stage defined as stages 0 to 2 and high-stage as stages 3 to 4. The primary outcome was all-cause mortality. Early intervention was defined as that within 1 year of index echocardiography.

We included 2,490 patients with moderate AS. The mean age was 73.3 ± 10.9 years, and 53.6% were men. Of these, 1,926 were categorized in the lowstage and 564 in the highstage. The cumulative incidence of intervention did not differ between the 2 groups. During a median follow-up of 3.5 (interquartile range, 1.4-6.3) years, 980 patients died. Patients in the high stage were associated with a significantly higher mortality risk (adjusted hazard ratio [aHR] = 1.33; 95% CI, 1.13-1.56; P < .001). Early intervention was associated with improved survival in the high-stage (aHR = 0.45; 95% CI, 0.26-0.79; P = .006) but not in the low-stage group (aHR = 0.76; 95% CI, 0.52-1.09; P = .137). Consistent results were demonstrated in the propensity score-matched cohorts (high stage, aHR = 0.44; 95% CI, 0.24-0.83, P = .010; low stage, aHR = 0.75; 95% CI, 0.49-1.15; P = .190).

In patients with moderate AS, early intervention may be associated with improved survival in those with advanced extravalvular cardiac damage.