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. 2014 Sep 14;35(35):2372-81.
doi: 10.1093/eurheartj/ehu044. Epub 2014 Feb 19.

Perioperative risk of major non-cardiac surgery in patients with severe aortic stenosis: a reappraisal in contemporary practice

Teruko Tashiro  1 , Sorin V Pislaru  1 , Jodi M Blustin  1 , Vuyisile T Nkomo  1 , Martin D Abel  2 , Christopher G Scott  3 , Patricia A Pellikka  4
Affiliations

Perioperative risk of major non-cardiac surgery in patients with severe aortic stenosis: a reappraisal in contemporary practice

Teruko Tashiro et al. Eur Heart J. .

Abstract

Aims: Severe aortic stenosis (SAS) is a major risk factor for death after non-cardiac surgery, but most supporting data are from studies over a decade old. We evaluated the risk of non-cardiac surgery in patients with SAS in contemporary practice.

Methods and results: SAS patients (valve area ≤1 cm(2), mean gradient ≥40 mmHg or peak aortic velocity ≥4 m/s) undergoing intermediate or high-risk surgery were identified from surgical and echo databases of 2000-2010. Controls were matched for age, sex, and year of surgery. Post-operative (30 days) death and major adverse cardiovascular events (MACE), including death, stroke, myocardial infarction, ventricular tachycardia/fibrillation, and new or worsening heart failure, and 1-year survival were determined. There were 256 SAS patients and 256 controls (age 76 ± 11, 54.3% men). There was no significant difference in 30-day mortality (5.9% vs. 3.1%, P = 0.13). Severe aortic stenosis patients had more MACE (18.8% vs. 10.5%, P = 0.01), mainly due to heart failure. Emergency surgery, atrial fibrillation, and serum creatinine levels of >2 mg/dL were predictors of post-operative death by multivariate analysis [area under the curve: 0.81, 95% confidence intervals: 0.71-0.91]; emergency surgery was the strongest predictor of 30-day mortality for both SAS and controls. Severe aortic stenosis was the strongest predictor of 1-year mortality.

Conclusion: Severe aortic stenosis is associated with increased risk of MACE. In contemporary practice, perioperative mortality of patients with SAS is lower than previously reported and the difference from controls did not reach statistical significance. Emergency surgery is the strongest predictor of post-operative death. These results have implications for perioperative risk assessment and management strategies in patients with SAS.

Keywords: Aortic stenosis; Echocardiography; Non-cardiac surgery; Perioperative risk; Survival; Valvular heart disease.

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Figures

Figure 1
Figure 1
Outcomes after non-cardiac surgery. 30-day and 1-year survival in severe aortic stenosis patients (red) and controls (blue). The differences in mortality at 30 days did not reach statistical significance. However, severe aortic stenosis was associated with significantly higher mortality at 1 year. *P < 0.001.
Figure 2
Figure 2
Kaplan–Meier analysis of perioperative outcomes. There was no significant difference in perioperative survival between severe aortic stenosis patients and controls (A), the major determinant of perioperative mortality being emergency surgery (B; log-rank P-values: <0.001 for emergency vs. non-emergency surgery, 0.073 for severe aortic stenosis vs. controls during routine surgery, 0.87 for severe aortic stenosis vs. controls during emergency surgery). Hard endpoints (death, stroke, myocardial infarction, and ventricular tachycardia/fibrillation) occurred to a similar extent in patients and controls (C). However, when new or worsening heart failure was included with major adverse cardiovascular events, severe aortic stenosis patients were significantly more likely to develop events within the first 30 days after surgery (D). Severe aortic stenosis data are in red; controls are in blue.
Figure 3
Figure 3
Odds ratios for 30-day mortality. Results of univariate and multivariate logistic regression analysis. Data presented as odds ratios and 95% confidence intervals; P-values in parentheses. For continuous variables, odds ratios are given per unit change in the regressor. TR, more than moderate tricuspid regurgitation; Cr, creatinine; AVA, aortic valve area; RVSP, right ventricular systolic pressure; LAVI, left atrial volume index. Severe aortic stenosis was not a significant univariate predictor, but is presented for reference.
Figure 4
Figure 4
Odds ratios for 30-day major adverse cardiovascular events. Results of univariate and multivariate logistic regression analysis. Data presented as odds ratios and 95% confidence intervals; P-values in parentheses. For continuous variables, odds ratios are given per unit change in the regressor. Cr, creatinine; TR, more than moderate tricuspid regurgitation; MR, more than moderate mitral regurgitation; MI, myocardial infarction; SV, stroke volume; RVSP, right ventricular systolic pressure; LAVI, left atrial volume index.
Figure 5
Figure 5
Odds ratios for 1-year mortality. Results of univariate and multivariate logistic regression analysis. Data presented as odds ratios and 95% confidence intervals; P-values in parentheses. For continuous variables, odds ratios are given per unit change in the regressor. EF, ejection fraction; Cr, creatinine; CHF, congestive heart failure; TR, moderate, or more tricuspid regurgitation; MR, moderate or more mitral regurgitation; SV, stroke volume; AVA, aortic valve area; RVSP, right ventricular systolic pressure; LAVI, left atrial volume index.
Figure 6
Figure 6
Perioperative death and major adverse cardiovascular events by cardiac risk index. 30-day mortality (left) and major adverse cardiovascular events (right) increased with higher Revised Cardiac Risk Index. The differences between severe aortic stenosis and controls increased in magnitude at risk index of ≥2; at this level, severe aortic stenosis patients experienced significantly more major adverse cardiovascular events and had a strong trend for excess mortality.
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