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 cm(2)/m(2) 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.