Morgan L. Brown1, Patricia A. Pellikka2, Hartzell V. Schaff1, Christopher G. Scott3, Charles J. Mullany1, Thoralf M. Sundt1, Joseph A. Dearani1, Richard C. Daly1, Thomas A. Orszulak1; 1Cardiovascular Surgery, Mayo Clinic, Rochester, MN; 2Mayo Clinic - Cardiovascular Medicine, Rochester, MN; 3Mayo Clinic - Biostatistics, Rochester, MN
Objective: The prevalence of aortic valve stenosis (AS) increases with age, and often the diagnosis is made by echocardiography before symptoms develop. To address the controversies in management of asymptomatic patients with severe aortic stenosis, we assessed the early and late outcome of aortic valve replacement (AVR) in these patients.Methods: We analyzed data of 622 patients, aged 72±11 years, with isolated asymptomatic severe AS and a left ventricular ejection fraction of =40%. Patients were identified with a peak systolic velocity of >4m/s by transthoracic echocardiography and followed for the development of symptoms and need for AVR.
Results: After initial diagnosis, 154 (25%) patients who were initially asymptomatic developed chest pain, shortness of breath, or syncope, and had AVR at our Clinic. Another 95 (15%) patients had AVR in the absence of symptoms. Symptomatic patients were more likely to require coronary bypass grafting (p<.01) and have diabetes, hypercholesterolemia, and a lower ejection fraction (p<.05 for each). Operative mortality was 3% for symptomatic patients and 1% for asymptomatic patients (p=.40). The survival of the 249 patients who underwent AVR was not significantly different from an age and sex matched population (p=.99); 10-year survival was 61% (95% CI 53% to 69%) for symptomatic patients and 64% (95% CI 57% to 73%) for asymptomatic patients (p=.92). At 3 years, 52% (95% CI 48 to 56%) of 622 patients had developed symptoms, undergone AVR, or died. Among the entire cohort, older age at diagnosis (hazard 1.1,p<.001), diabetes (hazard 1.7,p<.001), decreased ejection fraction (hazard 1.1,p=0.01), symptoms (hazard 2.13,p<.001), and absence of AVR (hazard 3.53,p<.001) were identified as independent risk factors for mortality.
Conclusion: Among patients with severe AS who underwent AVR, early and late outcomes were similarly good in patients who developed symptoms compared to those who were asymptomatic. It is important to note that among patients with asymptomatic aortic stenosis, the omission of surgical treatment was the most important risk factor for late mortality.
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