Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery?

TLDR

The study aims to analyze decision‑making for surgery in elderly patients with severe symptomatic aortic stenosis. Using the Euro Heart Survey, 216 patients aged 75 or older with severe symptomatic aortic stenosis were evaluated, and their characteristics were compared between those who underwent surgery and those who did not. Among the cohort, 33% were denied surgery, with older age and left‑ventricular dysfunction strongly associated with non‑operative decisions, while comorbidity burden was less influential.

Abstract

Aims To analyse decision-making in elderly patients with severe, symptomatic aortic stenosis (AS). Methods and results In the Euro Heart Survey on valvular heart disease, 216 patients aged ≥75 had severe AS (valve area ≤0.6 cm2/m2 body surface area or mean gradient ≥50 mmHg) and angina or New York Heart Association class III or IV. Patient characteristics were analysed according to the decision to operate or not. A decision not to operate was taken in 72 patients (33%). In multivariable analysis, left ventricular (LV) ejection fraction [OR=2.27, 95% CI (1.32–3.97) for ejection fraction 30–50, OR=5.15, 95% CI (1.73–15.35) for ejection fraction ≤30 vs. >50%, P=0.003] and age [OR=1.84, 95% CI (1.18–2.89) for 80–85 years, OR=3.38, 95% CI (1.38–8.27) for ≥85 vs. 75–80 years, P=0.008] were significantly associated with the decision not to operate; however, the Charlson comorbidity index was not [OR=1.72, 95% CI (0.83–3.50), P=0.14 for index ≥2 vs. <2]. Neurological dysfunction was the only comorbidity significantly linked with the decision not to operate. Conclusion Surgery was denied in 33% of elderly patients with severe, symptomatic AS. Older age and LV dysfunction were the most striking characteristics of patients who were denied surgery, whereas comorbidity played a less important role.