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Original Articles: Adult Cardiac

Operative Risks and Survival in Veterans With Severe Aortic Stenosis: Surgery Versus Medical Therapy

Department of Surgery, University of California San Francisco Medical Center, and San Francisco Veterans Affairs Medical Center, San Francisco, California

Accepted for publication April 4, 2011.

^_* Address correspondence to Dr Tseng, UCSF Medical Center and San Francisco VAMC, Division of Cardiothoracic Surgery, 500 Parnassus Ave, Ste W405, Box 0118, San Francisco, CA 94143-0118 (Email: elaine.tseng{at}ucsfmedctr.org).

Background: Transcatheter aortic valves were developed as an alternative to surgery for the one third to two thirds of patients with severe aortic stenosis who do not undergo aortic valve replacement. In this study, we examined reasons for medical management of aortic stenosis in relation to operative risks and outcomes for veterans with and without valve replacement.

Methods: The echocardiography database was screened from 2000 to 2007 for severe aortic stenosis. The Society of Thoracic Surgeons risk scores and survival were determined for patients with and without aortic valve replacement.

Results: Of 132 severe aortic stenosis patients included, 42% were medically managed. Predicted operative mortality risk was lower for surgical patients than for medical patients (4.5% ± 4.2% versus 6.8% ± 5.1%, p = 0.002). Overall, the most common reason for medical management of aortic stenosis was assumption that the patient was high risk for surgery (30.4%). The surgery group had significantly higher median survival (92.2 versus 32.4 months) and 5-year survival (71% versus 37%, p < 0.001) than the medical group. Cardiac surgery was not consulted in 61% of medically managed patients, of whom only 18% had Society of Thoracic Surgeons risk score of 10 or greater. Aortic valve replacement was an independent predictor of lower mortality (hazard ratio 0.43, p = 0.008).

Conclusions: Although operative risk was higher among patients who did not undergo surgery, most were not the 10% or greater required for transcatheter valves. Given the significantly lower survival with medical therapy, aortic valve replacement should be carefully considered for most severe aortic stenosis patients whereas transcatheter aortic valves should be reserved for patients with high operative risks.