P482Very long-term outcomes of patients with severe aortic stenosis: the impact of treatment modality

Abstract

Background: The aim of this study was to assess very long‐term outcomes of high‐risk patients with severe aortic stenosis allocated to medical treatment (MT), surgical aortic valve replacement (SAVR), or transcatheter aortic valve implantation (TAVI). Methods: Consecutive unselected patients with severe aortic stenosis deemed at increased risk for surgery were analyzed from a prospective single center registry. Results were based on a competing risk model (myocardial infarction, stroke, and all‐cause death). Results: Between July 2007 and September 2010, 442 patients (median age 83 years; 52% female) were allocated to MT (n=78), SAVR (n=107), or TAVI (n=257) after interdisciplinary discussion within the Heart Team. Patients assigned to MT or TAVI had a significantly higher risk as assessed by the logistic EuroSCORE compared to SAVR patients (MT: 27.9±14.5%, TAVI: 24.7±24.9%, SAVR: 12.5±8.2%; p<0.001). After a median duration of follow‐up of 7 years, 6.4% of patients allocated to MT, 46.7% of patients undergoing SAVR, and 30.4% of patients assigned to TAVI were still alive (Figure 1). Notably, 14% of patients initially assigned to MT crossed over to SAVR (2.5%) or TAVI (11.6%), respectively. Both SAVR (HR 0.26, 95% CI 0.15‐0.47; p<0.0001) and TAVI (HR 0.49, 95% CI 0.31‐0.77; p=0.0021) reduced the risk of mortality as compared to MT with a number needed to treat of 2.5 for SAVR (95% CI 1.88‐3.81) and 3.1 for TAVI (95% CI 2.28‐4.97) at 6 months that remained stable throughout 7 years. Female sex (HR 0.68, 95% CI 0.53‐0.88; p=0.0006) and compromised left ventricular function (LVEF <40%) (HR 1.62, 95% CI 1.22‐2.15; p<0.0001) were associated with increased mortality. The risk of myocardial infarction (2.5%) and disabling stroke (5.7%) at 7 years was low and no statistically significant difference was observed between patients treated with SAVR, TAVI, and MT. Conclusion: While patients with severe aortic stenosis have a dismal prognosis with MT, patients treated with SAVR or TAVI have a comparable outcome after seven years of follow‐up. Taking into account that SAVR and TAVI patients differ in a variety of aspects, distinguished selection of adequate candidates for TAVI or SAVR remains of high importance.