Outcomes in asymptomatic, severe aortic stenosis.

BACKGROUND AND AIM OF THE STUDY: Patients with asymptomatic, severe aortic stenosis are presumed to have a benign prognosis. In this retrospective cohort study, we examined the natural history of contemporary patients advised against aortic valve replacement due to a perceived lack of symptoms. MATERIALS AND METHODS: We reviewed the medical records of every patient given the ICD-10-code for aortic stenosis (I35.0) at Oslo University Hospital, Rikshospitalet, between Dec 1st, 2002 and Dec 31st, 2016. Patients who were evaluated by the heart team due to severe aortic stenosis were categorized by treatment strategy. We recorded baseline data, adverse events and survival for the patients characterized as asymptomatic and for 100 age and gender matched patients scheduled for aortic valve replacement. RESULTS: Of 2341 patients who were evaluated for aortic valve replacement due to severe aortic stenosis, 114 patients received conservative treatment due to a lack of symptoms. Asymptomatic patients had higher mortality than patients who had aortic valve replacement, log-rank p<0.001 (mean follow-up time: 4.0 (SD: 2.5) years). Survival at 1, 2 and 3 years for the asymptomatic patients was 88%, 75% and 63%, compared with 92%, 83% and 78% in the matched patients scheduled for aortic valve replacement. 28 (25%) of the asymptomatic patients had aortic valve replacement during follow-up. Age, previous history of coronary artery disease and N-terminal pro B-type natriuretic peptide (NT-proBNP) were predictors of mortality and coronary artery disease and NT-proBNP were predictors of 3-year morbidity in asymptomatic patients. CONCLUSIONS: In this retrospective study, asymptomatic patients with severe aortic stenosis who were advised against surgery had significantly higher mortality than patients who had aortic valve replacement.

Prevalence and prognostic implication of iron deficiency and anaemia in patients with severe aortic stenosis.

Objective: The aim of this study was to evaluate the prevalence and prognostic implication of iron deficiency (ID) and anaemia in patients with severe aortic stenosis (AS). Methods: In an observational study of consecutive patients referred for aortic valve replacement (AVR), we assessed a wide range of biomarkers of iron status, including the definition of ID commonly applied in patients with chronic heart failure (ferritin <100 µg/L or ferritin 100-299 µg/L with a transferrin saturation <20%). The endpoints were short-term (one-year) and long-term (median 4.7 years, IQR: 3.8-5.5) mortality and major adverse cardiovascular events (MACE) within the first year after inclusion. Results: 464 patients were included in this substudy. 91 patients (20%) received conservative treatment and 373 patients (80%) received AVR. ID was detected in 246 patients (53%). 94 patients (20%) had anaemia. Patients with ID had an overall worse clinical profile than patients without ID. During follow-up, 129 patients (28%) died. Neither ID as defined above, soluble transferrin receptor nor hepcidin were associated with short-term or long-term mortality or MACE independent on treatment allocation. Anaemia was associated with one-year mortality in conservatively treated patients. Conclusions: ID and anaemia are prevalent in patients with severe AS. In our cohort, ID did not provide independent prognostic information on top of conventional risk factors. More studies are required to determine how to correctly diagnose ID in patients with AS. Trial registration number: NCT01794832.

Morbidity outcomes after surgical aortic valve replacement.

OBJECTIVE: In patients with mild to moderate operative risk, surgical aortic valve replacement (SAVR) is still the preferred treatment for patients with severe symptomatic aortic stenosis (AS). Aiming to broaden the knowledge of postsurgical outcomes, this study reports a broad set of morbidity outcomes following surgical intervention. METHODS: Our cohort comprised 442 patients referred for severe AS; 351 had undergone SAVR, with the remainder (91) not operated on. All patients were evaluated using the 6-minute walk test (6MWT), were assigned a New York Heart Association class (NYHA) and Canadian Cardiovascular Society class (CCS), with additional scores for health-related quality of life (HRQoL), cognitive function (Mini-Mental State Examination (MMSE)) and myocardial remodelling (at inclusion and at 1-year follow-up). Adverse events and mortality were recorded. RESULTS: Three-year survival after SAVR was 90.0%. SAVR was associated with an improved NYHA class, CCS score and HRQoL, and provoked reverse ventricular remodelling. The 6MWT decreased, while the risks of major adverse cardiovascular events (death, non-fatal stroke/transient ischaemic attack or myocardial infarction) and all-cause hospitalisation (incidence rate per 100 patient-years) were 13.5 and 62.4, respectively. The proportion of cognitive disability measured by MMSE increased after SAVR from 3.2% to 8.8% (p=0.005). Proportion of patients living independently at home, having attained NYHA class I, was met by 49.1% at 1 year. Unoperated individuals had a poor prognosis in terms of any outcome. CONCLUSION: This study provides knowledge of outcomes beyond what is known about the mortality benefit after SAVR to provide insight into the morbidity burden of modern-day SAVR.

Associations of brain-natriuretic peptide, high-sensitive troponin T, and high-sensitive C-reactive protein with outcomes in severe aortic stenosis.

OBJECTIVES: Among patients with severe aortic stenosis (AS), we investigated the associations of N-terminal pro-natriuretic peptide (NT-proBNP), high-sensitive troponin T (hsTnT), and high-sensitive C-reactive protein (hs-CRP) with 3-year mortality and major adverse cardiovascular events (MACE) during 1 year. METHODS: This observational cohort study prospectively enrolled 442 patients with severe AS who were referred for evaluation of possible valve replacement. Clinical data was recorded before the decision of whether to operate was made. We studied the prognostic value of assessing biomarkers by serum levels, and tested associations of NT-proBNP, hsTnT, and hs-CRP with clinical outcomes (3-year all-cause mortality and risk of MACE in the year following study inclusion) using adjusted multivariable analysis. RESULTS: Elevated serum levels of these biomarkers at baseline evaluation were associated with increased all-cause 3-year mortality regardless of treatment assignment. Adjusted analysis showed that none of the studied biomarkers (NT-proBNP, hsTnT or hs-CRP) or any other covariates were associated with 3-year all-cause mortality following surgical aortic valve replacement (SAVR). However, adjusted analyses showed that hsTnT (HR, 1.51; 95% CI, 1.11-2.05; P = 0.008) and left ventricular ejection fraction (HR 0.97; 95% CI 0.94-0.97, P = 0.043) was associated with MACE for operated patients. CONCLUSIONS: Whereas NT-proBNP, hsTnT and hs-CRP had no independently prognostic value in relation to all-cause mortality following SAVR, hsTnT was independently associated with MACE following operation. The use of these clinically available biomarkers, in particular hsTnT, should be clarified in larger studies.