Perioperative risk of major non-cardiac surgery in patients with severe aortic stenosis: a reappraisal in contemporary practice.

AIMS: Severe aortic stenosis (SAS) is a major risk factor for death after non-cardiac surgery, but most supporting data are from studies over a decade old. We evaluated the risk of non-cardiac surgery in patients with SAS in contemporary practice. METHODS AND RESULTS: SAS patients (valve area ≤1 cm(2), mean gradient ≥40 mmHg or peak aortic velocity ≥4 m/s) undergoing intermediate or high-risk surgery were identified from surgical and echo databases of 2000-2010. Controls were matched for age, sex, and year of surgery. Post-operative (30 days) death and major adverse cardiovascular events (MACE), including death, stroke, myocardial infarction, ventricular tachycardia/fibrillation, and new or worsening heart failure, and 1-year survival were determined. There were 256 SAS patients and 256 controls (age 76 ± 11, 54.3% men). There was no significant difference in 30-day mortality (5.9% vs. 3.1%, P = 0.13). Severe aortic stenosis patients had more MACE (18.8% vs. 10.5%, P = 0.01), mainly due to heart failure. Emergency surgery, atrial fibrillation, and serum creatinine levels of >2 mg/dL were predictors of post-operative death by multivariate analysis [area under the curve: 0.81, 95% confidence intervals: 0.71-0.91]; emergency surgery was the strongest predictor of 30-day mortality for both SAS and controls. Severe aortic stenosis was the strongest predictor of 1-year mortality. CONCLUSION: Severe aortic stenosis is associated with increased risk of MACE. In contemporary practice, perioperative mortality of patients with SAS is lower than previously reported and the difference from controls did not reach statistical significance. Emergency surgery is the strongest predictor of post-operative death. These results have implications for perioperative risk assessment and management strategies in patients with SAS.

Echocardiographic indices associated with frailty in adults ≥65 years.

Frailty is prevalent in patients with cardiovascular disease, but few studies have evaluated relations between frailty and echocardiographically determined cardiac indexes. To assess the prevalence of frailty and its association with echocardiographic characteristics, we prospectively measured frailty in 257 patients ≥65 years who underwent echocardiography (transthoracic echocardiography [TTE]) from June 2012 to February 2013. Deficits of weight loss, exhaustion, physical activity, gait speed, and handgrip strength were used to categorize patients as frail (≥3 features), intermediately frail (1 or 2 features), or nonfrail (0 features). Pearson correlation was used to examine bivariate associations between TTE variables and frailty. Kaplan-Meier methods were used to estimate overall survival based on frailty status. A multivariable model was used to examine TTE indexes associated with frailty while accounting for age and baseline cardiac co-morbidities. Of the 257 patients studied, 40 (15.6%) were nonfrail, 167 (65.0%) intermediately frail, and 50 (19.4%) frail. Left atrial volume (r = 0.14; p = 0.03), stroke volume (r = -0.19; p <0.01), E/A ratio (r = 0.26; p <0.001), and pulmonary artery systolic pressure (r = 0.33; p <0.001) correlated with fraility. After age and baseline cardiac comorbidities were accounted for, larger left atrial volumes, lower stroke volumes, and higher pulmonary artery systolic pressures remained independently associated with frailty. Frail patients had worse survival compared with nonfrail and intermediately frail patients (p = 0.016 by log-rank). In conclusion, 1/5 of older patients who underwent clinically indicated TTE were frail, with worse survival and a unique fingerprint of TTE findings distinguishing them from nonfrail patients.