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Ann Thorac Surg 2010;89:453-458. doi:10.1016/j.athoracsur.2009.10.033
© 2010 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Severe Aortic Stenosis in a Veteran Population: Treatment Considerations and Survival

Faisal G. Bakaeen, MDa,c,*, Danny Chu, MDa,c, Mark Ratcliffe, MDd, Raja R. Gopaldas, MDa,c, Alvin S. Blaustein, MDb, Raghunandan Venkat, MDa, Joseph Huh, MDa,c, Scott A. LeMaire, MDa,c, Joseph S. Coselli, MDa,c, Blase A. Carabello, MDb

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).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
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.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
The decision to perform aortic valve replacement (AVR) in patients with severe symptomatic aortic stenosis (AS) is straightforward and constitutes the standard of care [1]. There are, however, new and evolving challenges regarding the treatment of patients with severe AS. These challenges are related to an aging population, recent advancements in medical and surgical care, and the rapid evolution of minimally invasive transcatheter technology.

The aging of the US population [2] may change the number and type of AS cases that US physicians treat. Because calcific AS is the predominant valve disease in the elderly [3], we are likely to witness a sharp rise in the number of patients with severe AS. The medical and surgical communities should anticipate this increase and set guidelines and allocate resources accordingly.

Recent advancements in medical and surgical care may change the stage of development at which AS cases are treated. Because symptom development is associated with poor survival [4], patients with asymptomatic AS have traditionally been treated expectantly, and surgery has been reserved until symptoms develop or until concomitant coronary artery bypass grafting surgery is indicated. However, recent advancements in cardiac surgery, improvements in myocardial protection, and the increased longevity of bioprosthetic valves favor earlier surgical intervention and placing less emphasis on symptoms in surgical decision making [5–9].

The advent of minimally invasive transcatheter technologies for treating valve disease [10, 11] may lead to a paradigm shift in the treatment of patients with severe AS. Although we are at a very early stage of its development, transcatheter valve implantation has generated a lot of interest and prompted a recent collaborative professional position statement [12].

Against this background, little is known about the care path of contemporary patients after they are diagnosed with severe AS. We hypothesized that surgically treated AS patients are only one part of a much larger pool of patients with severe AS. Therefore, we reviewed the treatment of all patients who were diagnosed with severe AS at our institution, and we focused specifically on the factors that influenced the choice of treatment modality (surgical versus medical). In addition, we analyzed the differences in survival between patients who underwent AVR and those who were treated medically.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Patients
After obtaining institutional review board approval and waiver of informed consent, we retrospectively reviewed the medical records of all patients diagnosed with severe AS at the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) from January 1997 to April 2008. The MEDVAMC is a major affiliate of Baylor College of Medicine and provides cardiac care to veterans in southern Texas, Louisiana, and southern Oklahoma. Patients with severe AS were identified from the echocardiographic database maintained by the Division of Cardiology. For the purposes of inclusion in this study, we defined severe AS as an aortic valve area less than 1.0 cm2. We excluded patients (n = 16) who had previous AVR, incomplete echocardiographic data, or no follow-up data.

A total of 345 patients who fit our criteria were identified, and a detailed chart review was conducted to extract relevant demographic, clinical, echocardiographic, surgical, and follow-up data. A total of 205 patients underwent AVR surgery, whereas 140 patients were medically treated. The reasons behind the choice of treatment (surgical versus medical) were identified and recorded. At our institution, the decision regarding management of severe AS typically involves close collaboration between the cardiologists and cardiac surgeons. Patient-related factors, including patient preference, are important considerations.

We extracted the Department of Veterans Affairs Continuous Improvement in Cardiac Surgery Program's (CICSP) risk covariates (and used their associated definitions), including age, serum creatinine level, history of endocarditis, chronic obstructive pulmonary disease, current smoking status, cerebrovascular disease, diabetes, New York Heart Association heart failure class, functional status, peripheral vascular disease, and ejection fraction [13]. For the purposes of this study, we used comorbidities as an umbrella term to cover a range of noncardiac disease entities, including cancer, liver disease, renal disease, pulmonary disease, and central and peripheral vascular disease. Data on prescribed medications, including β-blockers, statins, and antiplatelet drugs, were not complete and could not be evaluated in this study.

Follow-up data were available for all patients and started from the date of the first echocardiogram that indicated an aortic valve area less than 1.0 cm2. The study end point, namely all-cause mortality, was determined from the Veterans Affairs Computerized Patient Record System, which contains pertinent information on the vital status of each patient. The National Social Security Death Index was used as a supplementary source of mortality data.

Statistical Methods
All data were analyzed with SAS version 9.1 (SAS Institute Inc, Cary, NC). All demographic and clinical variables were compared between the AVR group and the medical group by using Student's t tests for continuous variables and Fisher's exact test or {chi}2 test for categorical variables. Overall survival at 1, 3, and 5 years was estimated by the Kaplan-Meier method and expressed as percentage ± 95% confidence interval (CI). Stepwise Cox regression was used to identify CICSP covariates that were significantly associated with survival.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
Patient Care Path
Of the 345 patients with the diagnosis of severe AS, 260 patients (75%) were evaluated by a cardiac surgeon (Fig 1). Only 205 patients (59%) underwent AVR; the remaining 140 patients (41%) were treated medically. The most common primary reasons for the choice of medical treatment for a patient were the patient's decision to decline surgical referral or surgical intervention, severe comorbidities, asymptomatic status, poor functional status, dementia, and advanced age. From the surgeon's perspective, the primary reasons for choosing medical treatment were severe comorbidities, poor functional status, porcelain aorta, asymptomatic status, and low cardiac ejection fraction. The details of the comorbidities that affected decision making are summarized in Table 1.


Figure 1
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  		Fig 1. Patient care path after diagnosis of severe aortic stenosis (AS). (AVR = aortic valve replacement.)

 

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  		Table 1 Primary Reasons for Medical (Rather Than Surgical) Treatment of Patients With Severe Aortic Stenosis
 
The AVR group was significantly 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), including New York Heart Association functional class III or IV and Canadian Cardiovascular Society angina class III or IV, than the medical group. The medical patients had a lower cardiac ejection fraction (0.42 ± 0.15 versus 0.50 ± 0.12; p < 0.001) and were less likely to be functionally independent (64% versus 74%; p = .0456) than the AVR patients.

Surgery
In addition to AVR, 40.1% (83 of 205) of patients underwent coronary artery bypass grafting, and 4.9% (10 of 205) underwent aortic root or ascending aortic repair. Five patients underwent a concomitant left atrial ablation procedure for atrial fibrillation. There were no concomitant procedures involving other valves. There was mild or moderate mitral regurgitation in 60.5% (124 of 205) of patients but no mitral regurgitation severe enough to prompt surgical correction. The overall 30-day or in-hospital mortality rate was 6.3% (13 of 205).

Survival
Survival rates after diagnosis were significantly higher in the AVR group than in the medical group at 1 year (92%; 95% CI, 87% to 95%; versus 65%; 95% CI, 56% to 72%), 3 years (85%; 95% CI, 79% to 90%; versus 29%; 95% CI, 21% to 37%), and 5 years (73%; 95% CI, 65% to 80%; versus 16%; 95% CI, 9% to 23%; log-rank test p < 0.0001; Fig 2). Cox proportional hazard modeling, after adjusting for preexisting conditions, indicated that the AVR group had a hazard ratio for mortality of 0.17 (95% CI, 0.10 to 0.27; p < 0.0001) compared with the medical group. The predictors of mortality were older age, higher serum creatinine level, lower cardiac ejection fraction, the presence of chronic obstructive pulmonary disease, the presence of cerebrovascular disease, and, counterintuitively, the absence of peripheral vascular disease (Table 2).


Figure 2
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  		Fig 2. Survival rates after diagnosis of severe aortic stenosis in patients treated medically and those treated by aortic valve replacement (AVR).

 

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  		Table 2 Predictors of Mortality According to the Cox Proportional Hazard Model
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
Aortic valve replacement is the established standard of care for patients with severe, symptomatic AS. But not all patients with severe AS are referred for surgical consideration or are deemed surgical candidates by the evaluating surgeon. In our study, only 59% of all patients with severe AS underwent AVR. This is consistent with the results of a large, single-center series from the United States in which only half of patients with severe AS underwent AVR [14]. In the Euro Heart Survey [15], surgeons decided against performing AVR in 33% of elderly patients with severe, symptomatic AS. Older age and left ventricular dysfunction were the most common characteristics of patients who were not treated surgically, whereas comorbidity played a less important role. In our experience significant patient comorbidities, asymptomatic status, poor patient functional status, and dementia were the most common reasons why physicians chose medical treatment for their AS patients.

Patients with severe AS who have a limited life expectancy owing to severe noncardiac disease are unlikely to benefit from AVR. Many of the comorbidities that influenced the choice of treatment (AVR versus medical) for our patients with severe AS are not captured by traditional cardiac risk models. Patients with terminal illness such as advanced incurable cancer, end-stage pulmonary disease, advanced liver cirrhosis, or ongoing uncontrollable sepsis (excluding surgical endocarditis) may be anatomically operable, but to subject such patients to surgery or any invasive procedure is clearly inappropriate. Severe irreversible pulmonary hypertension that is associated with primary pulmonary (rather than cardiac) disease also contraindicates AVR. Renal failure that is captured by cardiac risk models is particularly ominous in patients with severe AS, especially if the renal failure has an acute onset and is associated with other organ dysfunction. Consideration should be given to mechanically supporting the heart to reverse organ dysfunction before proceeding with AVR. In our opinion, patients with major debilitating stroke or with advanced dementia that renders them unable to care for themselves are best treated medically. Patients with severe and debilitating noncardiac disease are not only at higher risk for operative mortality but are also likely to have a limited life expectancy regardless of the treatment modality chosen. Severe AS becomes a secondary concern in those patients who are better treated with palliative medical measures.

The importance of cardiac symptoms in determining the timing of surgical referral of patients with severe AS is a subject of intense interest. In this era of advanced perioperative care and improved surgical outcomes, there is a growing body of literature that supports earlier surgical intervention and less emphasis on symptoms [5–9]. We believe that "asymptomatic" patients often inadvertently reduce their activity level and mask their symptoms. In our experience, many AS patients initially labeled as asymptomatic are found to be symptomatic on further evaluation and often have abnormal left ventricular echocardiographic manifestations. We adopt a more conservative but watchful approach for severe AS patients who are truly asymptomatic; this approach is characterized by optimal medical treatment and close follow-up with serial echocardiography. Surgery is considered as soon as symptoms develop or when adverse changes in cardiac function or dimensions are detected. We pay particular attention to the morphology and calcification of the leaflets. In our experience, patients with heavily calcified and restricted leaflets and those with bicuspid aortic valves are likely to experience a rapid progression in AS severity and symptom onset and warrant earlier intervention.

The deterioration of functional capacity is a tricky issue in terms of surgical decision making, because it may in fact be a subtle manifestation of cardiac symptoms, rather than the result of comorbid conditions that might contraindicate surgery. If the decline in functional status is simultaneous with worsening degree of aortic stenosis or worsening cardiac function, then doing the surgery can reverse the decline in function by correcting the underlying cardiac cause. To help us in treatment decision making in certain select instances, we have performed balloon aortic valvuloplasty to ascertain whether a brief window of improvement or optimization may be achieved, which would suggest a potential benefit of AVR for the patient.

Although advanced age (>80 years) was the primary reason for nonsurgical treatment in only a few cases (8 of 140), age probably played an indirect role in the choice of medical treatment over AVR through age-associated comorbidities and declining functional status. It is projected that by the year 2020, approximately 20 million Americans will be 80 years or older [2]. The prevalence of AS increases with age, and the lack of effective medical treatment to prevent aortic valve stenosis or halt its progression can only increase the health-care burden imposed by this condition [16, 17]. Most contemporary series of AVR operations in patients aged 80 years and older have shown good outcomes, including satisfactory long-term survival rates [18–20]. However, the medical community has been somewhat reluctant to refer very elderly patients for AVR. This reluctance persists despite recent evidence that the quality of life of octogenarians after AVR is comparable to that predicted for the age-matched general population [21]. Physicians should consider patient age in the context of the entire clinical picture, rather than assigning an arbitrary cutoff age for medical versus surgical intervention.

Also, there is no cutoff value for ejection fraction when it comes to offering or declining surgical intervention; instead, we consider evaluating the cardiac contractile reserve, especially in AS patients with low ejection fraction and low gradient, to refine the risk stratification process. A particularly challenging scenario is a small annulus in an AS patient with low ejection fraction or low gradient. Every effort should be made to use the largest possible valve, and consideration should be given to performing root enlargement at the time of AVR to minimize the transprosthetic gradient, which is poorly tolerated in these high-risk patients. Depending on other patient-related factors, including age and comorbidities, the risks imposed by surgery may be prohibitive.

Patients who are deemed high-risk for traditional AVR because of anatomic or technical surgical considerations (eg, porcelain aorta, multiple previous cardiac operations), with or without other medical risk factors, are particularly challenging to treat but may be candidates for alternative interventional modalities. Patients with less than moderate aortic regurgitation and a segment of the descending aorta that is suitable for clamping are considered for apical to descending valved conduit bypass.

Transcatheter aortic valve implantation is a new strategy in the armamentarium of AS treatments. However, currently, about half of the patients referred for transcatheter aortic valve intervention are either deemed unsuitable candidates or end up undergoing traditional AVR [22]. The technology is still in its infancy, and as more data become available to support the safety and efficacy of the procedure, carefully selected patients who are deemed high risk for traditional AVR may benefit from this procedure. Rigorous evaluation of transcatheter technology with adequate follow-up is needed before any major paradigm shift in the treatment of severe AS can take place.

With rising health-care costs and with AS being predominantly a senile disease, socioeconomic and ethical considerations come into play. Furthermore, quality of life is an important outcome that is often overlooked and that should be carefully evaluated as we consider different treatment modalities for AS. Offering surgical or percutaneous intervention that may extend the life of a patient with debilitating comorbidities or advanced dementia comes at a risk and price that is sometimes hard for the patient, the patient's family, and society to accept. Our job as responsible and caring professionals is to offer AVR or other interventions that extend functional and reasonably contented lives.

There are several limitations to our study. It is retrospective in nature and has a relatively small sample size; thus, it is vulnerable to all the weaknesses and biases associated with such a design. Although we reviewed the cardiac echocardiogram reports to verify the severity of AS, we did not independently review the echocardiogram images and verify the valve measurements. Follow-up echocardiographic data were limited because 65% of our patients were referred from remote hospitals. Once these patients are discharged, they are followed up by their local primary care physician or cardiologist; therefore, follow-up echocardiograms were not uniformly available. As a result, we could not study the effects of AVR on long-term ventricular remodeling.

Our risk model covariates were derived from the CICSP, which is generated from a national veterans cardiac surgical cohort and does not track variables that are rarely encountered in such a population (eg, dementia, cirrhosis) but are more common in medically managed patients. In addition, the only outcome we examined was all-cause mortality; we did not track adverse cardiovascular events. Our study is novel because it addresses a timely topic that has been inadequately studied: the patterns of referral and treatment of patients with severe AS. We examined factors that are often overlooked in reports on this subject, such as factors involved in patient selection for surgical intervention versus medical treatment.

In conclusion, despite medical advancements and newer treatment modalities, the management of patients with severe AS can be challenging and is best approached in a multidisciplinary setting with surgical expertise to navigate the complex process of risk assessment and to select patients who would benefit from the survival advantage associated with AVR.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
Stephen N. Palmer, PhD, ELS, contributed to the editing of this manuscript, and Shubhada Sansgiry, PhD, provided statistical support.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) J Am Coll Cardiol 2006;48:e1-e148.[Medline]
  2. US interim projections by age, sex, race, and Hispanic originhttp://www.census.gov/ipc/www/usinterimproj 2006Accessed April 24, 2009.
  3. Aronow WS, Kronzon I. Prevalence and severity of valvular aortic stenosis determined by Doppler echocardiography and its association with echocardiographic and electrocardiographic left ventricular hypertrophy and physical signs of aortic stenosis in elderly patients Am J Cardiol 1991;67:776-777.[Medline]
  4. Ross Jr J, Braunwald E. Aortic stenosis Circulation 1968;38:61-67.[Medline]
  5. Pellikka PA, Sarano ME, Nishimura RA, et al. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up Circulation 2005;111:3290-3295.[Abstract/Free Full Text]
  6. Dal-Bianco JP, Khandheria BK, Mookadam F, Gentile F, Sengupta PP. Management of asymptomatic severe aortic stenosis J Am Coll Cardiol 2008;52:1279-1292.[Medline]
  7. Brown ML, Pellikka PA, Schaff HV, et al. The benefits of early valve replacement in asymptomatic patients with severe aortic stenosis J Thorac Cardiovasc Surg 2008;135:308-315.[Abstract/Free Full Text]
  8. Mihaljevic T, Nowicki ER, Rajeswaran J, et al. Survival after valve replacement for aortic stenosis: implications for decision making J Thorac Cardiovasc Surg 2008;135:1270-1279.[Abstract/Free Full Text]
  9. Pai RG, Kapoor N, Bansal RC, Varadarajan P. Malignant natural history of asymptomatic severe aortic stenosis: benefit of aortic valve replacement Ann Thorac Surg 2006;82:2116-2122.[Abstract/Free Full Text]
  10. Lichtenstein SV, Cheung A, Ye J, et al. Transapical transcatheter aortic valve implantation in humans: initial clinical experience Circulation 2006;114:591-596.[Abstract/Free Full Text]
  11. Webb JG, Chandavimol M, Thompson CR, et al. Percutaneous aortic valve implantation retrograde from the femoral artery Circulation 2006;113:842-850.[Abstract/Free Full Text]
  12. Vahanian A, Alfieri OR, Al-Attar N, et al. Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Eur J Cardiothorac Surg 2008;34:1-8.[Abstract/Free Full Text]
  13. Grover FL, Johnson RR, Shroyer AL, Marshall G, Hammermeister KE. The Veterans Affairs Continuous Improvement in Cardiac Surgery Study Ann Thorac Surg 1994;58:1845-1851.[Abstract/Free Full Text]
  14. Bach DS, Cimino N, Deeb GM. Unoperated patients with severe aortic stenosis J Am Coll Cardiol 2007;50:2018-2019.[Medline]
  15. Iung B, Cachier A, Baron G, et al. Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? Eur Heart J 2005;26:2714-2720.[Abstract/Free Full Text]
  16. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study Lancet 2006;368:1005-1011.[Medline]
  17. Freeman RV, Otto CM. Spectrum of calcific aortic valve disease: pathogenesis, disease progression, and treatment strategies Circulation 2005;111:3316-3326.[Free Full Text]
  18. Thourani VH, Myung R, Kilgo P, et al. Long-term outcomes after isolated aortic valve replacement in octogenarians: a modern perspective Ann Thorac Surg 2008;86:1458-1465.[Abstract/Free Full Text]
  19. Melby SJ, Zierer A, Kaiser SP, et al. Aortic valve replacement in octogenarians: risk factors for early and late mortality Ann Thorac Surg 2007;83:1651-1657.[Abstract/Free Full Text]
  20. Grossi EA, Schwartz CF, Yu PJ, et al. High-risk aortic valve replacement: are the outcomes as bad as predicted? Ann Thorac Surg 2008;85:102-107.[Abstract/Free Full Text]
  21. Sundt TM, Bailey MS, Moon MR, et al. Quality of life after aortic valve replacement at the age of >80 years Circulation 2000;102(Suppl 3):III-70-III-74.[Abstract/Free Full Text]
  22. Otten AM, van Domburg RT, van Gameren M, et al. Population characteristics, treatment assignment and survival of patients with aortic stenosis referred for percutaneous valve replacement EuroIntervention 2008;4:250-255.[Medline]



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