Original article
Prognosis of Patients With Severe Aortic Stenosis After the Decision to Perform an InterventionEvolución de los pacientes con estenosis aórtica grave tras la indicación de intervención

https://doi.org/10.1016/j.rec.2018.03.023Get rights and content

Abstract

Introduction and objectives

Current therapeutic options for severe aortic stenosis (AS) include transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Our aim was to describe the prognosis of patients with severe AS after the decision to perform an intervention, to study the variables influencing their prognosis, and to describe the determinants of waiting time > 2 months.

Methods

Subanalysis of the IDEAS (Influence of the Severe Aortic Stenosis Diagnosis) registry in patients indicated for TAVI or SAVR.

Results

Of 726 patients with severe AS diagnosed in January 2014, the decision to perform an intervention was made in 300, who were included in the present study. The mean age was 74.0 ± 9.7 years. A total of 258 (86.0%) underwent an intervention: 59 TAVI and 199 SAVR. At the end of the year, 42 patients (14.0%) with an indication for an intervention did not receive it, either because they remained on the waiting list (34 patients) or died while waiting for the procedure (8 patients). Of the patients who died while on the waiting list, half did so in the first 100 days. The mean waiting time was 2.9 ± 1.6 for TAVI and 3.5 ± 0.2 months for SAVR (P = .03). The independent predictors of mortality were male sex (HR, 2.6; 95%CI, 1.1-6.0), moderate-severe mitral regurgitation (HR, 2.6; 95%CI, 1.5-4.5), reduced mobility (HR, 4.6; 95%CI, 1.7-12.6), and nonintervention (HR, 2.3; 95%CI, 1.02-5.03).

Conclusions

Patients with severe aortic stenosis awaiting therapeutic procedures have a high mortality risk. Some clinical indicators predict a worse prognosis and suggest the need for early intervention.

Resumen

Introducción y objetivos

Los tratamientos actuales de la estenosis aórtica (EAo) grave incluyen el implante percutáneo de válvula aórtica (TAVI) y la cirugía de sustitución valvular aórtica (SVAo). El objetivo es describir la evolución de los pacientes con EAo grave tras la indicación de intervención, las variables que influyen en su pronóstico y los determinantes de un tiempo de espera superior a 2 meses.

Métodos

Subanálisis del registro IDEAS (Influencia del Diagnóstico de Estenosis Aórtica Severa) en los pacientes a los que se indicó intervención.

Resultados

De 726 pacientes con EAo grave diagnosticada en enero de 2014, se indicó intervención a 300 que son el foco del presente estudio. La media de edad era 74,0 ± 9,7 años. Se intervino a 258 pacientes (86,0%): 59 con TAVI y 199 con SVAo. Al año, 42 (14,0%) continuaban sin intervención, ya sea por seguir en espera (34) o haber fallecido (8). La mitad de los pacientes que murieron antes del procedimiento fallecieron en los primeros 100 días. El tiempo hasta la intervención fue 2,9 ± 1,6 meses para el TAVI y 3,5 ± 0,2 meses para la SVAo (p = 0,03). Los predictores de mortalidad independientes fueron el sexo masculino (HR = 2,6; IC95%, 1,1-6,0), la insuficiencia mitral moderada-grave (HR = 2,6; IC95%, 1,5-4,5), la movilidad reducida (HR = 4,6; IC95%, 1,7-12,6) y la falta de intervención (HR = 2,3; IC95%, 1,02-5,03).

Conclusiones

Los pacientes con EAo grave en espera de intervención tienen alto riesgo de mortalidad. Hay indicadores clínicos asociados con peor pronóstico que podrían indicar la necesidad de una intervención precoz.

Section snippets

INTRODUCTION

Aortic stenosis (AS) is the most frequent heart valve disease in developed countries.1, 2 AS is especially common in persons older than 75 years, among whom its prevalence is more than 3%,2, 3 and prognosis is poor once symptoms appear.4 Prognosis is improved by surgical aortic valve replacement (SAVR), and this procedure has been proposed as a treatment option even for patients with asymptomatic severe AS.5 Moreover, for symptomatic patients at high or intermediate surgical risk with SAVR,

METHODS

The IDEAS registry14 prospectively included consecutive patients with severe AS diagnosed by transthoracic ultrasound at 48 Spanish centers during January 2014; the diagnostic criteria were a mean gradient ≥ 40 mmHg or an aortic valve area < 1 cm2 calculated by the continuity equation,15 together with an absence of previous valve intervention. The 1-year follow-up assessment recorded vital status and surgical or transcatheter valve intervention. Treatment centers were classified according to

RESULTS

Of the 726 AS patients in the IDEAS registry, 300 were candidates for intervention (290 with symptomatic AS and 10 with ventricular dysfunction). These 300 patients were the subject of this substudy; the remaining patients were assigned to conservative treatment. The mean age of the substudy population was 74.0 ± 9.7 years, and 155 patients (51.7%) were men. During the 1-year observation period, 258 patients (86%) underwent intervention, 199 by SAVR and 59 by TAVI (all via the transfemoral

DISCUSSION

This substudy analyzed mean intervention waiting time and mortality predictors in severe AS patients assigned to aortic valve intervention. Identified mortality risk factors were male sex, moderate or severe mitral regurgitation, and nonintervention. Knowledge of these risk factors has the potential to help identify high-risk patients who would benefit from early intervention or close clinical management.

Only 36% of patients in the IDEAS registry received aortic valve intervention, with all

CONCLUSIONS

Patients with severe AS on the intervention waiting list are at high risk of death. Waiting times for SVAR are longer than for TAVI. Clinical indicators associated with poor prognosis are available that could be used to prioritize patients for early intervention.

CONFLICTS OF INTEREST

E. Abu-Assi is an Associate Editor at the Revista Española de Cardiología.

WHAT IS KNOWN ABOUT THE TOPIC?

  • Symptomatic severe AS is associated with a high 1-year mortality, and the only available treatments are SAVR or TAVI. Nevertheless, patients with an indication for intervention seldom receive it immediately.

  • For various reasons, waiting times to intervention are highly variable across geographic regions; moreover, previous studies have reported different mortality rates among patients experiencing long delays before

Acknowledgments

We thank Dr. Enrique Gutiérrez Ibañes for his invaluable help in the execution of this study.

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