Longitudinal Surgical Aortic Valve Replacement Outcomes for Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction.

Abstract

Recent evidence supports early intervention in patients with asymptomatic aortic stenosis (AS) and normal ejection fraction. The study objective was to compare longitudinal surgical aortic valve replacement (SAVR) outcomes in asymptomatic vs symptomatic patients with normal left ventricular ejection fraction (LVEF). The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was leveraged to identify patients who underwent isolated SAVR for asymptomatic or symptomatic severe AS with LVEF ≥50% between July 2011 and December 2022. The cohort was linked to Centers for Medicare & Medicaid Services data. The primary outcome was risk-adjusted 10-year survival. Subgroup analysis evaluated long-term survival stratified by age, LVEF, and STS predicted risk of mortality (PROM). A total of 17,683 patients with LVEF ≥50% underwent isolated SAVR; 16,284 (92.1%) were symptomatic and 1399 (7.9%) were asymptomatic. Compared with symptomatic patients, asymptomatic patients were younger (mean age, 74.2 vs 75.0 years; P < .001) and had lower STS PROM (1.9% ± 1.4% vs 2.5% ± 2.0%; P < .001). After risk adjustment, asymptomatic patients demonstrated superior 10-year survival compared with symptomatic patients (adjusted hazard ratio [aHR], 1.19 [95% CI, 1.09-1.29]). In subgroup analyses, long-term survival benefit was more pronounced in asymptomatic vs symptomatic patients aged ≥75 years (aHR, 1.24 [95% CI, 1.11-1.39]), LVEF ≥60% (aHR, 1.20 [95% CI, 1.08-1.34]), and STS PROM <2% (aHR, 1.17 [95% CI, 1.01-1.34]). In patients with severe AS and preserved LVEF, SAVR before symptom onset shows superior long-term survival. This study supports early SAVR in carefully selected patients with asymptomatic severe AS.