Increased risk profile in the treatment of patients with symptomatic degenerative aortic valve stenosis over the last 10 years

Abstract

Introduction: Currently, Cardiology Centres are overfilled with patients with degenerative aortic valve stenosis (DAS), usually eldery, with severe concommittant comorbidities, who are referred for further decisions and possible intervention.

Aim: To evaluate changes in the risk profile of patients with severe DAS admitted to the cardiology department a decade ago compared with patients currently being admitted.

Material and methods: We retrospectively evaluated all patients admitted with confirmed severe DAS, hospitalized during 2005-2006 (group I: 140 patients) and in 2016 (group II: 152 patients), admitted for aortic valve intervention. A standard transthoracic echocardiogram, cardiovascular symptom and risk factor distribution, perioperative risk with the logistic EuroSCORE II and STS mortality scores were obtained.

Results: Patients in group II were significantly older (p < 0.001), had more cardiovascular risk factors, and more often presented with atrial fibrillation (27% vs. 11.4%, p = 0.001), renal impairment (34.9% vs. 22.8%; p = 0.024), severe lung disease (17.1% vs. 2.1%, p < 0.001), and extracardiac arteriopathy (40.1% vs. 17.8%, p < 0.001). The aortic valve area (AVA) (p = 0.356), mean-transvalvular pressure gradient (p = 0.215), and left ventricular ejection fraction (p = 0.768) were similar in both groups. However, the prevalence of pulmonary hypertension, severe mitral regurgitation, and low-flow, low-gradient DAS were 3.1-, 8.4- and 1.84-fold more frequent in group II than group I. The percentages of subjects with EuroSCORE II and STS scores ≥ 4% in 2005-2006 were 7.1% and 6.4%, as compared to 27% and 26.3% in 2016 (both p < 0.001). 22% of patients in 2016, as compared to 31% in 2005/2006, were considered ineligible for DAS intervention.

Conclusions: In just a decade, the risk profile of patients admitted with DAS has increased hugely, mainly due to older age, accumulation of comorbidities and more advanced disease at presentation. Although transcatheter aortic valve intervention has expanded the indications for intervention in high-risk patients, the number of patients disqualified from interventional treatment remains high.

Keywords: EuroSCORE II; STS score; aortic valve replacement; degenerative aortic valve stenosis; risk assessment; transcatheter aortic valve intervention.

Figure 1

A – Comparison of mean EuroSCORE II and STS scores in group I and group II, B – prevalence of patients with high risk of perioperative mortality STS and EuroSCORE > 4%

Figure 2

A – Patients referred for aortic valve replacement (AVR) or optimal medical treatment (OMT) in 2005–2006. B – Patients referred for AVR, OMT, transcatheter aortic valve replacement (TAVI) and balloon aortic valvuloplasty (BAV) in 2016