80 percent of aortic stenosis patients are in the same/better health 1 year after treatment

A survey, published online in the European Journal of Cardio-Thoracic Surgery, of 13,860 patients who had undergone interventions for aortic valve disease in Germany has revealed that over 80% were in the same or a better state of health one year after the intervention, and was satisfied with the procedural outcome.

01 aug 2014--Aortic stenosis : the narrowing of the aortic valve in the heart – is the most frequent valvular heart disease in the aging Western population, and the prognosis of this disease in symptomatic patients with conservative therapy is poor. As a result, surgical aortic valve replacement (AVR) has become the therapeutic gold standard with well-documented benefits in terms of symptom relief and survival. During the past decade, transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative for higher-risk patients, and the number of these procedures being carried out in Germany and Europe as a whole has increased in recent years.

Prof. Dr. Friedrich W. Mohr and colleagues used the German Aortic Valve Registry (GARY) to look at the 13,860 registered patients undergoing either AVR or TAVR procedures from 2011. Enrolment in the Registry was voluntary, and took place in 78 German centres. Baseline, procedural, and outcome data, including quality of life, were acquired up to one year post-intervention. Vital status at one year was known for just over 98% of patients.

One-year mortality was 6.7% (6,523) for conventional AVR patients and 11% (3,464) for patients who underwent AVR with coronary artery bypass grafting. One-year mortality 20.7% and 28% in transvascular TAVR and transapical TAVR procedures respectively. However, if patients were stratified into four risk groups, the highest-risk cohorts showed the same mortality at one year regardless of type of therapy.

Over 80% of patients in all groups were in the same or better state of health at one year post-intervention and were satisfied with the procedural outcome.

Prof. Dr. Mohr said: 'GARY is unique in that it includes all interventional and surgical treatment options for aortic valve disease that are currently available in Germany. Our aim was to obtain a comprehensive and contemporary picture of the current practice of aortic valve intervention therapy and to create an independent database that will allow for long-term follow-up of those patients.

'The acceptance of this voluntary registry is demonstrated by the fact that 55% of all aortic valve procedures performed in Germany in 2011 were included, with an increasing recruitment rate observed in 2012. In addition, a good follow-up rate of 98.5% with regards to vital status and 90% for clinical information was achieved.

'The one-year results of the German Aortic Valve Registry confirm in a large "real world", all-comer patient population that conventional surgery in operable patients yields excellent results in all risk groups. TAVR is being performed in a significant proportion of cases and is a good alternative for high-risk patients. Continuation of the registry and long-term follow-up will help to develop robust future risk models to predict patient outcomes for each treatment option in patients with aortic stenosis.'

Provided by Oxford University Press

Can Patients with Critical Aortic Stenosis Undergo Noncardiac Surgery
without Intervening Aortic Valve Replacement?

M. Chadi Alraies
30 mar 2009--Case Presentation: A 65-year-old female patient with past medical history of
hypertension, diabetes mellitus, and hyperlipidemia was seen for preoperative
clearance for repair of right femur fracture. Patient denied chest pain but admitted
to progressively worsening dyspnea on exertion over the last few months. Her
medications were lisinopril, metformin, and simvastatin. Vital signs on admission
were stable, with a blood pressure of 136/72 mm Hg and heart rate of 92
bpm. Labs were normal. Her exam was unremarkable except for a 3/6 harsh systolic
murmur. Echocardiogram revealed critical aortic stenosis (AS) with valve
area of 0.7 cm2. Cardiology recommended aortic valve replacement (AVR), but
patient refused surgery. Patient chose to undergo fracture repair surgery despite
the explained risks. She was started on beta-blockers and appropriate anesthetic
precautions were undertaken. Her postoperative course was complicated by prolonged
ventilator support, but patient was successfully extubated after 2 days and
was discharged in stable condition.

Discussion: Per the American College of Cardiology/American Heart
Association guidelines, severe valvular disease is a major clinical predictor
of cardiac risk and elective noncardiac surgery (NCS) should be delayed for
intervening cardiac catheterization and/or possible valve surgery. However,
several reviews have suggested that patients with severe AS may undergo
NCS with relative safety if appropriate perioperative care is provided and
careful management of the pathophysiologic changes associated with AS
is undertaken. O’Keefe et al reported that in 48 severe AS patients (mean
valve area 0.6 cm2) who were not eligible for AVR and underwent NCS,
only 1 cardiac event with no deaths and a complication rate of about 2%
was seen. This would compare favorably with the national 4% mortality rate
for AVR reported by the Society of Thoracic Surgeons. On the other hand, a
subsequent report of 19 patients with severe AS (mean valve area < 0.5 cm2)
reported 2 perioperative deaths. Raymer and Yang compared 55 patients with
signifi cant AS (mean valve area 0.9 cm2) with case-matched controls with
similar preoperative risk profi les other than AS undergoing similar surgeries,
and cardiac complication rates were not signifi cantly different between
the two groups. Thus, patients with severe AS may undergo indicated NCS
provided that the presence of severe AS is recognized preoperatively and the
patients receive intensive perioperative care.

Conclusion: Critical AS needs to be detected preoperatively, given its prognostic
importance. When detected, surgery may still be considered even if AVR
is not feasible, and requires a comprehensive co-management team involving
anesthesia, cardiology, surgery, and internal medicine.