Incidence, determinants, and prognostic impact of operative refusal or denial in octogenarians with severe aortic stenosis.

Piérard, Sophie F. [UCL] Seldrum, Stéphanie [UCL] de Meester de Ravenstein, Christophe [UCL] Pasquet, Agnes [UCL] Gerber, Bernhard [UCL] Vancraeynest, David [UCL] El Khoury, Gebrine [UCL] Noirhomme, Philippe [UCL] Robert, Annie [UCL] Vanoverschelde, Jean-Louis [UCL]

Background. Aortic stenosis (AS) is a common valve disease in octogenarians. Previous studies have shown that aortic valve replacement (AVR) is frequently not performed in these patients. The aim of the present study was to investigate the incidence, determinants and prognostic impact of AVR denial in these patients. Method. Between 2000 and 2007, 163 octogenarians (mean age 84±3 years) with severe AS and an indication for surgery according to guidelines were prospectively included in an echocardiographic registry. Among these patients, 97 underwent AVR, whereas 66 were treated conservatively. Results. Logistic regression analysis identified older age, a lower transaortic pressure gradient, a larger aortic valve area and the presence of diabetes as independent predictors of AVR refusal or denial. In patients undergoing AVR, 30-day mortality was 9%. Overall 5-year survival was better in AVR patients than in those treated conservatively (66% vs 31%, log rank p<0.001 vs. AVR). After adjustment for the propensity score, patients undergoing AVR still had a better outcome than conservatively treated patients (p=0.022, HR:0.56, 95%CI [0.29-0.91]). Finally, in addition to the therapeutic decision, Cox regression analysis also identified a low body weight, a NYHA class III/IV, and the logistic EuroScore as independent predictors of outcome in the overall series Conclusion. About 40% of octogenarians with severe AS and a definite indication for surgery either refuse or are denied AVR. AVR refusal or denial has a profound impact on long-term prognosis as it results in a 2-fold excess mortality, even after adjustment for the propensity score.