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Mortality and worsening of prognostic profile during waiting time for valve replacement in aortic stenosis
O Lund1, T T Nielsen, K Emmertsen
1Department of Thoracic and Cardiovascular Surgery, Skejby Sygehus, Aarhus University Hospital, Denmark.
Insights
Severe aortic stenosis patients face serious risks during surgical waiting times, with a high death rate and worsened prognosis impacting long-term survival after aortic valve replacement.
Area of Science:
- Cardiology
- Cardiac Surgery
- Clinical Outcomes Research
Background:
- Severe aortic stenosis (AS) necessitates aortic valve replacement (AVR).
- Patients face significant waiting times for AVR, averaging 6.3 months in this study.
- The clinical implications of prolonged waiting periods for AS patients are not fully understood.
Purpose of the Study:
- To evaluate the outcomes of patients with severe AS placed on a surgical waiting list for AVR.
- To identify predictors of mortality and prognosis worsening during the waiting period.
- To assess the impact of waiting time on post-AVR survival.
Main Methods:
- Prospective study of 99 consecutive patients with severe AS awaiting AVR.
- Patients categorized into three groups: uneventful waiting period, prognosis worsening, and death during waiting.
- Logistic regression and Cox models used to identify predictors of adverse events and survival.
Main Results:
- The waiting-list death rate was 13.5% patient-year⁻¹, significantly higher than the post-AVR death rate of 4.9% patient-year⁻¹.
- A subgroup of patients experienced significant prognosis worsening during the waiting period, leading to reduced observed post-AVR survival (60% at 7 years vs. predicted 72%).
- Independent predictors of adverse outcomes included high age, short symptom duration, ECG abnormalities, female sex, and impaired diastolic function.
Conclusions:
- Prolonged surgical waiting times for severe AS patients are associated with high mortality and significant prognosis deterioration.
- Predictive models for identifying high-risk patients during the waiting period require improvement for clinical utility.
- Urgent intervention is crucial to mitigate the serious consequences of waiting for AVR in severe AS patients.
Abstract:
In a prospective study 99 consecutive patients with operative indication due to severe aortic stenosis (AS) were put on a surgical waiting list. The waiting-time to aortic valve replacement (AVR) averaged 6.3 months (0.5-19 months). There were 58 men and 41 women with a mean age of 61 years (21-82 years). The patients were divided into three groups: group I (n = 81) with an uneventful stay on the waiting list (including one patient who declined the AVR offer); group II (n = 11) with significant worsening of a prognostic index; and group III (n = 7) with patients who died during the waiting-time. The waiting-list death rate was 13.5 +/- 5.0% patient-year-1 compared with a post-AVR death rate of 4.9 +/- 0.9%. patient-year-1 (p < 0.05) with a mean post-AVR follow-up of 5.7 years. According to their prognostic index at inclusion, group II patients had a predicted (by a Cox model) 7-year post-AVR survival probability of 72%, but only of 61% according to their prognostic index immediately preoperatively; their observed 7-year post-AVR survival was 60%. Logistic regression analysis identified high age, short duration of symptoms, severe hypertrophy and strain in the ECG, female sex, and deranged left-ventricular diastolic function (related to severely increased left-ventricular muscle mass) as independent predictors of death on the waiting-list and prognosis worsening. From a clinical viewpoint, the predictive models did not allow sufficiently accurate identification of the patients at risk during the waiting-time. The consequences of a surgical waiting-time averaging 6 months are serious for AS patients. The death rate is high and a subgroup worsen their prognostic profile, with significantly reduced post-AVR long-term survival as the result.