Contemporary Management of Severe Symptomatic Aortic Stenosis.

Background: There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS).
Objectives: This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey.
Methods: Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention.
Results: A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age-adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001).
Conclusions: A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians.
Competing Interests: Funding Support and Author Disclosures Since the start of EORP, the following companies have supported the program: Abbott Vascular Inc (2011-2021), Amgen Cardiovascular (2009-2018), AstraZeneca (2014-2021), Bayer AG (2009-2018), Boehringer Ingelheim (2009-2019), Boston Scientific (2009-2012), Bristol Myers Squibb–Pfizer Alliance (2011-2019), Daiichi-Sankyo Europe GmbH (2011-2020), Alliance Daiichi-Sankyo Europe GmbH and Eli Lilly and Company (2014-2017), Edwards (2016-2019), Gedeon Richter Plc (2014-2016), Menarini International Operations (2009-2012), MSD-Merck and Co (2011-2014), Novartis Pharma AG (2014-2020), ResMed (2014-2016), Sanofi (2009-2011), Servier (2009-2018), and Vifor (2019-2022). Dr Prendergast has received grants and personal fees from Edwards Lifesciences; has received personal fees from Abbott and Anteris outside the submitted work. Dr Wendler has received personal fees from Edwards Lifesciences and Neovasc during the conduct of the study. Dr Bax has received grants from Abbott, Edwards Lifesciences, Medtronic, Boston Scientific, Biotronik, GE Healthcare, and Bayer; and has received personal fees from Abbott during the conduct of the study. Dr Vahanian has received personal fees from Edwards Lifesciences, Medtronic, and Abbott Vascular during the conduct of the study; and has received personal fees from Edwards Lifesciences, Medtronic, Abbott Vascular, and Cardiovalve outside the submitted work. Dr Iung has received personal fees from Edwards Lifesciences; and has received travel fees from Boehringer Ingelheim outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
(Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)