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

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.

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