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AVR reduces mortality risk, improves survival in asymptomatic aortic stenosis
Patients with asymptomatic aortic stenosis who were followed up at heart valve centers had a reduced risk for sudden death and similar rates of overall survival compared with earlier series of data, according to a study published in JAMA Cardiology.
HAVEC registry
Patrizio Lancellotti, MD, PhD, head of the cardiology department at the University of Liège Hospital in Belgium, and colleagues analyzed data from 1,375 patients (mean age, 71 years; 61% men) from the HAVEC registry with aortic stenosis diagnosed by echocardiogram. Patients visited one of 10 participating heart valve clinics between 2001 and 2014.
Follow-up was conducted every 6 to 12 months according to available guidelines. Patients either underwent direct interviews and clinical examination or phone interviews. Autopsy records and death records were reviewed for those who died during the study. Researchers collected information on subsequent aortic valve replacement, development of cardiac symptoms and death. Patients with unclear symptomatic status underwent exercise tests.
The primary endpoint was all-cause mortality, and the secondary endpoint was defined as CV-related mortality.
Severe aortic stenosis, defined as an aortic valve area less than 1 cm2, was seen in 62.6% of patients.
During a mean follow-up of 27 months, the mean overall survival during medical management was 93% at 2 years, 86% at 4 years and 75% at 8 years. Death occurred in 7.6% of patients, and 54.8% of those died from CV causes. The crude rate of sudden death throughout the study was 0.65%.
TAVR vs. surgical AVR
AVR was performed in 39.4% of patients (310 patients underwent surgical AVR; 78 patients underwent transcatheter AVR), of whom 71.6% had severe aortic stenosis at baseline and 28.4% had moderate aortic stenosis at baseline but progressed to severe aortic stenosis throughout the study. Patients with severe aortic stenosis underwent AVR at a mean of 14.4 months and a median of 8.7 months.
The AVR-free survival rate in patients with asymptomatic severe aortic stenosis at 2 years was 54% and 32% at 4 years. Mortality at 30 days after AVR was 0.9%.
Left ventricular ejection fraction less than 60% (P = .03) and peak aortic jet velocity greater than 5 m/s (P = .02) were associated with CV and all-cause mortality in patients with severe aortic stenosis at baseline. Peak aortic jet velocity and LVEF were also associated with postprocedural mortality in patients with severe aortic stenosis who underwent AVR.
“These findings provide support for consideration of early elective AVR in these patients,” Lancellotti and colleagues wrote. “Closer and more frequent (every 6 to 12 months) clinical and echocardiographic follow-up might be implemented in patients with moderate [aortic stenosis] and a peak aortic jet velocity of 3 m/s or greater or LVEF less than 60%.”
In a related editor’s note, Patrick T. O’Gara, MD, professor of medicine at Brigham and Women’s Hospital, and past president of the American College of Cardiology, and Robert O. Bonow, MD, vice chair for development and innovation in the department of medicine, Max and Lilly Goldberg Distinguished Professor of Cardiology and professor of medicine at Northwestern University Feinberg School of Medicine, and past president of the American Heart Association, wrote: “If validated in other studies, these observations could influence decision making and the timing of surgical referral. However, as the authors acknowledge, there are limitations to their analysis that could serve as a stimulus to improve both data collection and patient management.” – by Darlene Dobkowski
Disclosures: Lancellotti, O’Gara and Bonow report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.