Prognosis of Severe Asymptomatic Aortic Stenosis With and Without Surgery

Background: This study sought to determine outcomes in patients with severe, asymptomatic aortic stenosis (AS), stratified by treatment recommendation. Methods: Between January 2005 and December 2013, 4,998 patients had severe AS by echocardiography, of whom 308 were identified as asymptomatic by medical record review. Five patients were deemed inoperable, and 38 were lost to follow-up. Of the remaining 265 patients, aortic valve replacement (AVR) was recommended in 104, and watchful waiting (WW) was recommended in 161. Probabilities of undergoing surgery and of death from recommendation date were estimated using a multistate model. Cox regression analysis was used to determine independent risk factors for death. Results: Probability of death at 1 year after recommendation was 5.2% in the WW group and 4.7% in the AVR group. At 2 years after recommendation, survival in the AVR-recommended group was 92.5% versus 83.9% in the WW group (p = 0.044). In the WW group, the probability of dying or undergoing surgery was 43.9% by 2 years. Undergoing surgery was independently associated with higher survival in the AVR-recommended group (hazard ratio [HR], 0.17; p = 0.038) and in the WW group (HR, 0.39; p = 0.044). A higher ejection fraction (HR, 0.58; p < 0.001) was associated with better survival, whereas renal failure (HR, 2.81; p = 0.009) was associated with worse survival. Conclusions: The strategy of early AVR is associated with improved survival in asymptomatic patients.