Identification of high risk patients with severe but asymptomatic aortic stenosis

Whether asymptomatic patients with severe aortic stenosis benefit from surg ery remains unclear. We report our data recently published in the New Engla nd Journal of Medicine on the natural history of this disease and predictor s of outcome. 128 consecutive, asymptomatic patients with severe aortic stenosis (age 60/-18 years, peak aortic jet velocity 5.0+/- 0.6 m/s), were prospectively fo llowed from 1994 until 1998. During a mean follow-up duration of 22+/-18 mo nths, event-free survival, with end points defined as death or valve replac ement necessitated by the development of symptoms was 67+/-5 % at one year, 56+/-5 % at two years, and 33+/-5 % at 4 years. There were 8 deaths (6 car diac) and 59 underwent valve replacement. By multivariate analysis, only th e extent of aortic-valve calcification was an independent predictor of outc ome, but not age, sex, and the presence of coronary artery disease, hyperte nsion, diabetes, and hypercholesterolemia. Event-free survival for patients with no or mild calcification of the aortic valve was 92+/-5 % at one year , 84+/-8 % at two years, and 75+/-9 % at 4 years. In contrast, patients wit h moderate or severe calcification had an event-free survival of only 60+/- 6 %, 47+/-6 %, and 20+/-5 % at 1, 2, and 4 years, respectively. Patients wi th moderate or severe valve calcification and an increase in aortic jet vel ocity > 0.3 m/s within one year represented a high-risk group: 79 % of thes e patients underwent surgery or died within two years of the observed incre ase. In conclusion, moderate to severe aortic valve calcification and the observ ation of rapid hemodynamic progression identifies a high risk group of pati ents with asymptomatic severe aortic stenosis in which early elective surge ry should be considered rather than have surgery delayed until symptoms dev elop.