Korean Circ J.  2020 Sep;50(9):791-800. 10.4070/kcj.2020.0037.

Early Surgery versus Watchful Waiting in Patients with Moderate Aortic Stenosis and Left Ventricular Systolic Dysfunction

Affiliations
  • 1Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
  • 2Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
  • 3Department of Cardiovascular Thoracic Surgery, Seoul National University Hospital, Seoul, Korea

Abstract

Background and Objectives
Severe aortic stenosis (AS) with left ventricular systolic dysfunction (LVSD) is a class I indication for aortic valve replacement (AVR) but this recommendation is not well established in those at the stage of moderate AS. We investigate the clinical impact of AVR among patients with moderate AS and LVSD.
Methods
From 2001 to 2017, we consecutively identified patients with moderate AS and LVSD, defined as aortic valve area 1.0–1.5 cm2 and left ventricular ejection fraction <50%. The primary outcome was all-cause death. The outcomes were compared between those who underwent early surgical AVR (within 2 years of index echocardiography) at the stage of moderate AS versus those who were followed medically without AVR at the outpatient clinic.
Results
Among 255 patients (70.1±11.3 years, male 62%), 37 patients received early AVR. The early AVR group was younger than the medical observation group (63.1±7.9 vs. 71.3±11.4) with a lower prevalence of hypertension and chronic kidney disease. During a median 1.8-year follow up, 121 patients (47.5%) died, and the early AVR group showed a significantly lower all-cause death rate than the medical observation group (5.03PY vs. 18.80PY, p<0.001). After multivariable Cox-proportional hazard regression adjusting for age, sex, comorbidities, and laboratory data, early AVR at the stage of moderate AS significantly reduced the risk of death (hazard ratio, 0.43; 95% confidence interval 0.20–0.91; p=0.028).
Conclusions
In patients with moderate AS and LVSD, AVR reduces the risk of all-cause death. A prospective randomized trial is warranted to confirm our findings.

Keyword

Aortic stenosis; Heart valve prosthesis implantation; Heart failure; Prognosis
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