Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis

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• 作者：Tomohiko Taniguchi ; MD^&lowast ; ; Takeshi Morimoto ; MD ; MPH^&dagger ; ; Hiroki Shiomi ; MD^&lowast ; ; Kenji Ando ; MD^&Dagger ; ; Norio Kanamori ; MD^§ ; ; Koichiro Murata ; MD^‖ ; Takeshi Kitai ; MD^¶ ; ; Yuichi Kawase ; MD^# ; Chisato Izumi ; MD^&lowast ; &lowast ; ; Makoto Miyake ; MD^&lowast ; &lowast ; ; Hirokazu Mitsuoka ; MD^&dagger ; &dagger ; ; Masashi Kato ; MD^&Dagger ; &Dagger ; ; Yutaka Hirano ; MD^§ ; § ; ; Shintaro Matsuda ; MD^&lowast ; ; Kazuya Nagao ; MD^‖‖ ; Tsukasa Inada ; MD^‖‖ ; Tomoyuki Murakami ; MD^¶ ; ¶ ; ; Yasuyo Takeuchi ; MD^## ; Keiichiro Yamane ; MD^&lowast ; &lowast ; &lowast ; ; Mamoru Toyofuku ; MD^&dagger ; &dagger ; &dagger ; ; Mitsuru Ishii ; MD^&Dagger ; &Dagger ; &Dagger ; ; Eri Minamino-Muta ; MD^&lowast ; ; Takao Kato ; MD^&lowast ; ; Moriaki Inoko ; MD^§ ; § ; § ; ; Tomoyuki Ikeda ; MD^‖‖‖ ; Akihiro Komasa ; MD^¶ ; ¶ ; ¶ ; ; Katsuhisa Ishii ; MD^¶ ; ¶ ; ¶ ; ; Kozo Hotta ; MD^### ; Nobuya Higashitani ; MD^&lowast ; &lowast ; &lowast ; &lowast ; ; Yoshihiro Kato ; MD^&dagger ; &dagger ; &dagger ; &dagger ; ; Yasutaka Inuzuka ; MD^&Dagger ; &Dagger ; &Dagger ; &Dagger ; ; Chiyo Maeda ; MD^§ ; § ; § ; § ; ; Toshikazu Jinnai ; MD^&lowast ; &lowast ; &lowast ; &lowast ; ; Yuko Morikami ; MD^‖‖‖‖ ; Ryuzo Sakata ; MD^¶ ; ¶ ; ¶ ; ¶ ; ; Takeshi Kimura ; MD^&lowast ; ; ^{taketaka@kuhp.kyoto-u.ac.jp" class="auth_mail" title="E-mail the corresponding author} ; on behalf of the CURRENT AS Registry Investigators
• 关键词：aortic valve replacement ; propensity-matched ; registry ; risk ; watchful waiting
• 刊名：Journal of the American College of Cardiology
• 出版年：2015
• 出版时间：29 December 2015
• 年：2015
• 卷：66
• 期：25
• 页码：2827-2838
• 全文大小：977 K

文摘

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 cm²) 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)