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a Division of Cardiothoracic Surgery, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas
b Division of Cardiology, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas
c Section of Adult Cardiac Surgery, The Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas
d San Francisco Veterans Affairs Medical Center and the University of California–San Francisco, San Francisco, California
Accepted for publication October 13, 2009.
* Address correspondence to Dr Bakaeen, Department of Cardiothoracic Surgery, Michael E. DeBakey VAMC, OCL 112, 2002 Holcombe Blvd, Houston, TX 77030 (Email: fbakaeen{at}bcm.edu).
Background: We examined factors affecting the choice of surgical versus medical treatment of severe aortic stenosis and evaluated associated patient survival.
Methods: We retrospectively reviewed data from all patients diagnosed with severe aortic stenosis at a Veterans Affairs medical facility between January 1997 and April 2008.
Results: Of 345 patients with severe aortic stenosis, 260 (75%) underwent surgical evaluation, and 205 (59%) underwent aortic valve replacement (AVR). The patient's decision to decline surgical referral or AVR (n = 47) and severe comorbidities (n = 34) were the top two reasons for medical treatment rather than AVR. The AVR group was younger (69.5 ± 9.6 years versus 75.7 ± 8.6 years; p < 0.001) and had a higher prevalence of symptoms (96% versus 71%; p < 0.001) than the medical group. The medical group had a lower cardiac ejection fraction (0.42 ± 0.15 versus 0.50 ± 0.12; p < 0.001) and was less likely to be independent in activities of daily living (64% versus 74%). The AVR group had higher survival rates than the medical patients at 1 year (92% versus 65%), 3 years (85% versus 29%), and 5 years (73% versus 16%; log-rank test p < 0.0001). Valve replacement was independently associated with decreased mortality (hazard ratio, 0.17; 95% confidence interval, 0.10 to 0.27; p < 0.0001).
Conclusions: The management of severe aortic stenosis in veterans is sometimes limited to medical evaluation and treatment. Surgeons should be involved in the complex process of risk assessment, to select patients with severe aortic stenosis who would benefit from the survival advantage associated with AVR.
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