Deferral of AVR for Severe Aortic Stenosis During COVID-19 Associated With Worsening Heart Failure

Patients with symptomatic severe aortic stenosis who had aortic valve replacement (AVR) deferred vs expedited during the beginning of the coronavirus disease 2019 (COVID-19) pandemic were found to be more likely to be hospitalized for valve-related symptoms or worsening heart failure, according to a study published in JAMA Network Open.

In the Aortic Stenosis Defer cohort study, the data of 71 consecutively enrolled patients with symptomatic severe aortic stenosis who were referred for AVR starting at the beginning of the COVID-19 pandemic (ie, between March 20 and April 26, 2020) were examined.

Patients with critical aortic stenosis (ie, aortic valve area ≤0.6 cm²), transvalvular mean gradient ≥60 mm Hg, exercise intolerance with symptoms on minimal exertion, and those who had cardiac decompensation in the preceding 3 months were scheduled for expedited AVR (n=25; mean age, 79.6 years). Patients with an aortic valve area ≤1.0 cm² and >0.6 cm² and for whom symptoms were stable were deferred for AVR (n=46; mean age, 77.2 years). Patients were followed for a mean of 31±11 days after group allocation.

The study’s primary endpoint was a composite of all-cause mortality, disabling and nondisabling stroke, and unplanned hospitalization for valve-related symptoms or worsening heart failure. A total of 9 (19.6%) and 1 (4.0%) patients in the deferred and expedited AVR groups, respectively met the primary composite endpoint at follow-up (P =.08).

A greater percentage of hospitalizations for valve-related symptoms or worsening heart failure occurred in the deferred vs expedited AVR group (19.6% vs 0%, respectively; P =.02). Multivalvular disease was more common in patients who required hospitalization for valve-related symptoms or worsening heart failure who underwent deferred vs expedited AVR who also (44.4% vs 8.6%, respectively; P =.02).

Of patients hospitalized for valve-related symptoms or worsening heart failure, 7 (15.2%) switched from deferred AVR to expedited transcatheter (n=4) or surgical AVR (n=3) after the index treatment allocation (average, 17±11 days).

None of the patients died during the study period, but periprocedural nondisabling stroke was reported in 1 patient treated with expedited transcatheter AVR. Patients who experienced vs did not experience an event related to the primary outcome had a comparable delay between diagnosis confirmation and AVR referral (27 days vs 20 days, respectively; P =.58) and similar rates of New York Heart Association functional class ≥3 at baseline (60% vs 41%, respectively; P =.31).

Study limitations include the small sample size, which was due to the temporary ban on elective procedures at the beginning of the COVID-19 pandemic.

“Deferral of AVR in patients with symptomatic severe aortic stenosis was associated with an increased risk of hospitalization for valve-related symptoms or worsening heart failure,” concluded the study authors. “Patients with symptomatic severe aortic stenosis in combination with relevant multivalvular disease may particularly benefit from expedited AVR.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Ryffel C, Lanz J, Corpataux N, et al. Mortality, stroke, and hospitalization associated with deferred vs expedited aortic valve replacement in patients referred for symptomatic severe aortic stenosis during the COVID-19 pandemic. Published September 1, 2020. JAMA Netw Open. doi:10.1001/jamanetworkopen.2020.20402

This article originally appeared on The Cardiology Advisor