Impact of preoperative symptoms on postoperative survival in severe aortic stenosis: implications for the timing of surgery

Background: The impact of symptoms on the natural history of patients with severe aortic stenosis (SAS) has been well documented. By contrast, the implications of preoperative symptoms on postoperative outcomes remain poorly defined.

Methods: The long-term survival of 812 patients greater than 65 years old with SAS undergoing bioprosthetic aortic valve replacement (AVR) was analyzed according to their preoperative symptoms.

Results: Operative mortality was larger in New York Heart Association (NYHA) III-IV than in NYHA I-II patients (10% vs 6%, p = 0.036). Abrupt symptomatic deterioration from NYHA I to NYHA III-IV within the month preceding surgery was observed in 18% of NYHA III-IV patients and resulted in an increased operative mortality (17% vs 5% in NYHA I, p = 0.035). Long-term survival was also significantly worse in NYHA III-IV than in NYHA I-II patients (56% vs 72%, p = 0.002). Reduced long-term survival of NYHA III/IV patients was observed in subgroups with a left ventricular ejection fraction (LVEF) 0.50 or greater (58 vs. 74%, p = 0.008) and in those with a systolic pulmonary artery pressure (SPAP) less than 40 mm Hg (60% vs 74%, p = 0.014). By contrast, the presence of class III-IV symptoms did not influence outcome in patients with a LVEF less than 0.50 (51 vs. 55%, p = 0.34) or with a SPAP 40 mm Hg or greater (43% vs 48%, p = 0.78).

Conclusions: In patients with SAS, preoperative NYHA III-IV symptoms, particularly of recent onset, are independently associated with excess short- and long-term postoperative mortality. This was particularly evident in patients with normal LV function or pulmonary artery pressures. These findings plead in favor of an earlier surgical correction of SAS, before the onset of severe symptoms, especially in low-risk patients.