To operate or not on elderly patients with aortic stenosis: the decision and its consequences

Objective-To evaluate the application of guidelines in the decision making process leading to medical or surgical treatment for aortic stenosis in eld erly; patients. Design-Cohort analysis based on a prospective inclusive registry. Setting-205 consecutive patients (greater than or equal to 70 years) with c linically relevant isolated aortic stenosis and without serious comorbidity , seen for the first time in the Doppler-echocardiographic laboratories of three university hospitals in the Netherlands. Results-The initial choice was surgery in 94 patients and medical treatment in 111. Only 59% of the patients who should have had valve replacement acc ording to the practice guidelines were actually offered surgical treatment. These were mainly symptomatic patients under 80 years of age with a high g radient. Operative mortality (30 days) was only 2%. The three year survival was 80% in the surgical group (17 deaths among 94 patients) and 49% in the medical group (43/111). Multivariate analysis showed that only patients wi th a high baseline risk, mainly determined by impaired left ventricular fun ction, had a significantly better three year survival with surgical treatme nt than with medical treatment. Conclusions-In daily practice, elderly patients with clinically relevant sy mptomatic aortic stenosis are often denied surgical treatment. This study i ndicates that a surgical approach, especially where there is impaired systo lic left ventricular function, is associated with better survival.