Background Whether to perform valve replacement in patientswith asymptomatic but severe aortic stenosis is controversial.Therefore, we studied the natural history of this conditionto identify predictors of outcome.
Methods During 1994, we identified 128 consecutive patientswith asymptomatic, severe aortic stenosis (59 women and 69 men;mean [±SD] age, 60±18 years; aortic-jet velocity,5.0±0.6 m per second). The patients were prospectivelyfollowed until 1998.
Results Follow-up information was available for 126 patients(98 percent) for a mean of 22±18 months. Event-free survival,with the end point defined as death (8 patients) or valve replacementnecessitated by the development of symptoms (59 patients), was67±5 percent at one year, 56±5 percent at twoyears, and 33±5 percent at four years. Five of the sixdeaths from cardiac disease were preceded by symptoms. Accordingto multivariate analysis, only the extent of aortic-valve calcificationwas an independent predictor of outcome, whereas age, sex, andthe presence or absence of coronary artery disease, hypertension,diabetes, and hypercholesterolemia were not. Event-free survivalfor patients with no or mild valvular calcification was 92±5percent at one year, 84±8 percent at two years, and 75±9percent at four years, as compared with 60±6 percent,47±6 percent, and 20±5 percent, respectively,for those with moderate or severe calcification. The rate ofprogression of stenosis, as reflected by the aortic-jet velocity,was significantly higher in patients who had cardiac events(0.45±0.38 m per second per year) than those who didnot have cardiac events (0.14±0.18 m per second per year,P<0.001), and the rate of progression of stenosis provideduseful prognostic information. Of the patients with moderatelyor severely calcified aortic valves whose aortic-jet velocityincreased by 0.3 m per second or more within one year, 79 percentunderwent surgery or died within two years of the observed increase.
Conclusions In asymptomatic patients with aortic stenosis, itappears to be relatively safe to delay surgery until symptomsdevelop. However, outcomes vary widely. The presence of moderateor severe valvular calcification, together with a rapid increasein aortic-jet velocity, identifies patients with a very poorprognosis. These patients should be considered for early valvereplacement rather than have surgery delayed until symptomsdevelop.
Source Information
From the Department of Cardiology, Vienna General Hospital (R.R., T.B., G.P., I.L., G.C., G.M., H.B.) and the Ludwig Boltzmann Institute for Cardiovascular Research (R.R., T.B., G.P., I.L., G.C., G.M., H.B.); and the Department of Medical Computer Sciences (M.S.), University of Vienna — all in Vienna, Austria.
Address reprint requests to Dr. Baumgartner at the Department of Cardiology, Vienna General Hospital, University of Vienna, Währinger Gürtel 18–20, A-1090 Vienna, Austria, or at helmut.baumgartner{at}akh-wien.ac.at.
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