Early Surgery Versus Conventional Treatment in Asymptomatic Very Severe Aortic Stenosis

Background-The optimal timing of surgical intervention remains controversial in asymptomatic patients with very severe aortic stenosis. We therefore compared the long-term results of early surgery and a conventional treatment strategy. Methods and Results-From 1996 to 2006, we prospectively included a total of 197 consecutive asymptomatic patients (99 men; age, 63 +/- 12 years) with very severe aortic stenosis. Patients were excluded if they had angina, syncope, exertional dyspnea, ejection fraction < 0.50, significant mitral valve disease, or age > 85 years. Very severe aortic stenosis was defined as a critical stenosis in the aortic valve area <= 0.75 cm(2) accompanied by a peak aortic jet velocity >= 4.5 m/s or a mean transaortic pressure gradient >= 50 mm Hg on Doppler echocardiography. The primary end point was defined as the composite of operative mortality and cardiac death during follow-up. Early surgery was performed on 102 patients, and a conventional treatment strategy was used for 95 patients. There were no significant differences between the 2 groups in terms of age, gender, European System for Cardiac Operative Risk Evaluation score, or ejection fraction. During a median follow-up of 1501 days, the operated group had no operative mortalities, no cardiac deaths, and 3 noncardiac deaths; the conventional treatment group had 18 cardiac and 10 noncardiac deaths. The estimated actuarial 6-year cardiac and all-cause mortality rates were 0% and 2 +/- 1% in the operated group and 24 +/- 5% and 32 +/- 6% in the conventional treatment group, respectively (P < 0.001), and for 57 propensity score-matched pairs, the risk of all-cause mortality was significantly lower in the operated group than in the conventional treatment group (hazard ratio, 0.135; 95% confidence interval, 0.030 to 0.597; P = 0.008). Conclusions-Compared with the conventional treatment strategy, early surgery in patients with very severe aortic stenosis is associated with an improved long-term survival by decreasing cardiac mortality. Early surgery is therefore a therapeutic option to further improve clinical outcomes in asymptomatic patients with very severe aortic stenosis and low operative risk. (Circulation. 2010;121:1502-1509.)