Tomohiko Taniguchi1, Takeshi Morimoto2, Hiroki Shiomi1, Kenji Ando3, Norio Kanamori4, Koichiro Murata5, Takeshi Kitai6, Yuichi Kawase7, Chisato Izumi8, Makoto Miyake8, Hirokazu Mitsuoka9, Masashi Kato10, Yutaka Hirano11, Shintaro Matsuda1, Kazuya Nagao12, Tsukasa Inada12, Tomoyuki Murakami13, Yasuyo Takeuchi14, Keiichiro Yamane15, Mamoru Toyofuku16, Mitsuru Ishii17, Eri Minamino-Muta1, Takao Kato1, Moriaki Inoko18, Tomoyuki Ikeda19, Akihiro Komasa20, Katsuhisa Ishii20, Kozo Hotta21, Nobuya Higashitani22, Yoshihiro Kato23, Yasutaka Inuzuka24, Chiyo Maeda25, Toshikazu Jinnai22, Yuko Morikami26, Ryuzo Sakata27, Takeshi Kimura28. 1. Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan. 2. Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan. 3. Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan. 4. Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan. 5. Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan. 6. Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan. 7. Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan. 8. Department of Cardiology, Tenri Hospital, Tenri, Japan. 9. Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan. 10. Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan. 11. Department of Cardiology, Kinki University Hospital, Osakasayama, Japan. 12. Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan. 13. Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan. 14. Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan. 15. Department of Cardiology, Nishikobe Medical Center, Kobe, Japan. 16. Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan. 17. Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan. 18. Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan. 19. Department of Cardiology, Hikone Municipal Hospital, Hikone, Japan. 20. Department of Cardiology, Kansai Electric Power Hospital, Osaka, Japan. 21. Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan. 22. Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan. 23. Department of Cardiology, Saiseikai Noe Hospital, Osaka, Japan. 24. Department of Cardiology, Shiga Medical Center for Adults, Moriyama, Japan. 25. Department of Cardiology, Hamamatsu Rosai Hospital, Hamamatsu, Japan. 26. Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan. 27. Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan. 28. Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan. Electronic address: taketaka@kuhp.kyoto-u.ac.jp.
Abstract
BACKGROUND: Current guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS). OBJECTIVES: The study sought to compare the long-term outcomes of initial AVR versus conservative strategies following the diagnosis of asymptomatic severe AS. METHODS: We used data from a large multicenter registry enrolling 3,815 consecutive patients with severe AS (peak aortic jet velocity >4.0 m/s, or mean aortic pressure gradient >40 mm Hg, or aortic valve area <1.0 cm(2)) between January 2003 and December 2011. Among 1,808 asymptomatic patients, the initial AVR and conservative strategies were chosen in 291 patients, and 1,517 patients, respectively. Median follow-up was 1,361 days with 90% follow-up rate at 2 years. The propensity score-matched cohort of 582 patients (n = 291 in each group) was developed as the main analysis set for the current report. RESULTS: Baseline characteristics of the propensity score-matched cohort were largely comparable, except for the slightly younger age and the greater AS severity in the initial AVR group. In the conservative group, AVR was performed in 41% of patients during follow-up. The cumulative 5-year incidences of all-cause death and heart failure hospitalization were significantly lower in the initial AVR group than in the conservative group (15.4% vs. 26.4%, p = 0.009; 3.8% vs. 19.9%, p < 0.001, respectively). CONCLUSIONS: The long-term outcome of asymptomatic patients with severe AS was dismal when managed conservatively in this real-world analysis and might be substantially improved by an initial AVR strategy. (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis Registry; UMIN000012140).
BACKGROUND: Current guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS). OBJECTIVES: The study sought to compare the long-term outcomes of initial AVR versus conservative strategies following the diagnosis of asymptomatic severe AS. METHODS: We used data from a large multicenter registry enrolling 3,815 consecutive patients with severe AS (peak aortic jet velocity >4.0 m/s, or mean aortic pressure gradient >40 mm Hg, or aortic valve area <1.0 cm(2)) between January 2003 and December 2011. Among 1,808 asymptomatic patients, the initial AVR and conservative strategies were chosen in 291 patients, and 1,517 patients, respectively. Median follow-up was 1,361 days with 90% follow-up rate at 2 years. The propensity score-matched cohort of 582 patients (n = 291 in each group) was developed as the main analysis set for the current report. RESULTS: Baseline characteristics of the propensity score-matched cohort were largely comparable, except for the slightly younger age and the greater AS severity in the initial AVR group. In the conservative group, AVR was performed in 41% of patients during follow-up. The cumulative 5-year incidences of all-cause death and heart failure hospitalization were significantly lower in the initial AVR group than in the conservative group (15.4% vs. 26.4%, p = 0.009; 3.8% vs. 19.9%, p < 0.001, respectively). CONCLUSIONS: The long-term outcome of asymptomatic patients with severe AS was dismal when managed conservatively in this real-world analysis and might be substantially improved by an initial AVR strategy. (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis Registry; UMIN000012140).
Authors: E Mara Vollema; Tadafumi Sugimoto; Mylène Shen; Lionel Tastet; Arnold C T Ng; Rachid Abou; Nina Ajmone Marsan; Bart Mertens; Raluca Dulgheru; Patrizio Lancellotti; Marie-Annick Clavel; Philippe Pibarot; Philippe Genereux; Martin B Leon; Victoria Delgado; Jeroen J Bax Journal: JAMA Cardiol Date: 2018-09-01 Impact factor: 14.676