When to do Surgery - With or without symptoms?
When to do Surgery - With or without symptoms?
There is a definite split amongst heart doctors regarding when to do surgery. I am sending copies of 2 different articles addressing the issue of "When to do surgery" -and - "should the patient by symptomatic first"? You can see the varying opinions just from reading these reports.....
The second article is from Medscape. They can provide you with copies of many, many reports, regarding aortic valve replacement are are located at
http://www.medscape.com
Deb
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The New England Journal of Medicine is owned, published, and copyrighted © 2001
Massachusetts Medical Society
Volume 343:611-617
August 31, 2000
Number 9
Predictors of Outcome in Severe, Asymptomatic Aortic Stenosis
Raphael Rosenhek, M.D., Thomas Binder, M.D., Gerold Porenta, M.D., Irene Lang, M.D., Günther Christ, M.D., Michael Schemper, Ph.D., Gerald Maurer, M.D., and Helmut Baumgartner, M.D.
ABSTRACT
Background Whether to perform valve replacement in patients with asymptomatic but severe aortic stenosis is controversial. Therefore, we studied the natural history of this condition to identify predictors of outcome.
Methods During 1994, we identified 128 consecutive patients with asymptomatic, severe aortic stenosis (59 women and 69 men; mean [±SD] age, 60±18 years; aortic-jet velocity, 5.0±0.6 m per second). The patients were prospectively followed until 1998.
Results Follow-up information was available for 126 patients (98 percent) for a mean of 22±18 months. Event-free survival, with the end point defined as death (8 patients) or valve replacement necessitated by the development of symptoms (59 patients), was 67±5 percent at one year, 56±5 percent at two years, and 33±5 percent at four years.
Five of the six deaths from cardiac disease were preceded by symptoms. According to multivariate analysis, only the extent of aortic-valve calcification was an independent predictor of outcome, whereas age, sex, and the presence or absence of coronary artery disease, hypertension, diabetes, and hypercholesterolemia were not.
Event-free survival for patients with no or mild valvular calcification was 92±5 percent at one year, 84±8 percent at two years, and 75±9 percent at four years, as compared with 60±6 percent,
47±6 percent, and 20±5 percent, respectively, for those with moderate or severe calcification. The rate of progression of stenosis, as reflected by the aortic-jet velocity, was significantly higher in patients who had cardiac events (0.45±0.38 m per second per year) than those who did not have cardiac events (0.14±0.18 m per second per year,
P<0.001), and the rate of progression of stenosis provided useful prognostic information. Of the patients with moderately or severely calcified aortic valves whose aortic-jet velocity increased by 0.3 m per second or more within one year, 79 percent underwent surgery or died within two years of the observed increase.
Conclusions
In asymptomatic patients with aortic stenosis, it appears to be relatively safe to delay surgery until symptoms develop. However, outcomes vary widely. The presence of moderate or severe valvular calcification, together with a rapid increase in aortic-jet velocity, identifies patients with a very poor prognosis. These patients should be considered for early valve replacement rather than have surgery delayed until symptoms develop.
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From
Medscape Cardiology
Leading Opinion
Consideration on Surgical Intervention in Patients
With Asymptomatic Aortic Valve Stenosis
J. Willis Hurst, MD
[Medscape Cardiology, 2000. © 2000 Medscape, Inc.
There are 2 schools of thought about treatment for aortic valve stenosis in patients with
asymptomatic aortic valve stenosis. The members of one school favor medical management
and observation for such patients, even if the aortic-left ventricular systolic pressure gradient
is as large as it is in patients who have symptoms of heart failure, syncope, or angina. The
members of the other school of thought recommend aortic valve surgery in asymptomatic
patients when objective information indicates that the stenosis is severe.
I belong to the school of thought that recommends surgical replacement of the valve in
asymptomatic patients with aortic valve stenosis when all of the clinical data indicate that
stenosis is severe and the aortic-left ventricular gradient is as high as it is in symptomatic
patients. I have 2 reasons for this view. First of all, many people may have no symptoms
precisely because they restrict their activities. Secondly, left ventricular hypertrophy is a
serious matter in its own right; therefore, any stimulus to left ventricular hypertrophy should
be removed when it is possible to do so.
A new study in the August 31, 2000 issue of The New England Journal of Medicine
supports my view. In the article, Rosenhek and colleagues conclude that asymptomatic
patients with aortic valve stenosis who have moderate to severe calcification of the aortic
valve and a rapid increase in aortic-jet velocity by echocardiography should have aortic
valve surgery.
J. Willis Hurst, MD
Consultant of the Division of Cardiology
Emory University School of Medicine;
Former Professor and Chairman
Department of Medicine 1957-1986
Thank you for listening. 
