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Importance Modern data regarding incidence and modes of death of patients with aortic stenosis (AS) are restricted to tertiary centers or studies of aortic valve replacement (AVR). Objective To provide new insights into the natural history of outpatients with native AS based on a large regionwide population study with inclusion by all cardiologists regardless of their mode of practice. Design, Setting, and Participants Between May 2016 and December 2017, consecutive outpatients with mild (peak aortic velocity, 2.5-2.9 m/s), moderate (peak aortic velocity, 3-3.9 m/s), and severe (peak aortic velocity, ≥4 m/s) native AS graded by echocardiography were included by 117 cardiologists from the Nord-Pas-de-Calais region in France. Analysis took place between August and November 2020. Main Outcomes and Measures Natural history, need for AVR, and survival of patients with AS were followed up. Indications for AVR were based on current guideline recommendations. Results Among 2703 patients (mean [SD] age, 76.0 [10.8] years; 1260 [46.6%] women), 233 (8.6%) were recruited in a university public hospital, 757 (28%) in nonuniversity public hospitals, and 1713 (63.4%) by cardiologists working in private practice. A total of 1154 patients (42.7%) had mild, 1122 (41.5%) had moderate, and 427 (15.8%) had severe AS. During a median (interquartile range) of 2.1 (1.4-2.7) years, 634 patients underwent AVR and 448 died prior to AVR. Most deaths were cardiovascular (200 [44.7%]), mainly associated with congestive heart failure (101 [22.6%]) or sudden death (60 [13.4%]). Deaths were noncardiovascular in 186 patients (41.5%) and from unknown causes in 62 patients (13.8%). Compared with patients with mild AS, there was increased cardiovascular mortality in those with moderate (hazard ratio, 1.47 [95% CI, 1.07-2.02]) and severe (hazard ratio, 3.66 [95% CI, 2.52-5.31]) AS. The differences remained significant when adjusted for baseline characteristics or in time-dependent analyses considering AS progression. In asymptomatic patients, moderate and mild AS were associated with similar cardiovascular mortality (hazard ratio, 0.99 [95% CI, 0.44-2.21]). Conclusions and Relevance While patients in this study with moderate AS had a slightly higher risk of cardiovascular death than patients with mild AS, this risk was much lower than that observed in patients with severe AS. Moreover, in asymptomatic patients, moderate and mild AS were associated with similar cardiovascular mortality.

Aortic stenosis has become the most frequent type of valvular heart disease in Europe. Severe Aortic Stenosis (SAS) is defined as an aortic valve area b1 cm (or 0.6 cm/m), a mean transvalvular gradient N40 mmHg, a peak velocity N4 m/s, and permeability index b25% [1]. Some patients may have lower than expected transvalvular gradients (b40 mmHg) as a consequence of “low flow/low gradient SAS with depressed LVEF” or in the recently described “paradoxical low gradient aortic stenosis”. This survey was designed to explore practices on aortic valve stenosis, with particular interest for the management of patients with “nonclassical” aortic stenosis, for which guidelines were lacking in 2012. From June to November 2012, all graduated cardiologists of the region “Nord-Pas-de-Calais”were asked to answer a survey on SAS and received a questionnaire comprising 5 clinical scenarios of SAS. A choice of four different responses to each scenariowas proposed, i.e. surgical treatment, trans-aortic valve implantation, medical treatment with follow up or complementary explorations. An echocardiography specialist was defined as a cardiologist who performed more than 25 echocardiographies a week and an aortic stenosis specialist as a practitioner who diagnosed more than 40 aortic stenosis a year. Categorial variables were compared with the Chi-squared test of Pearson. A p-value≤ 0.05 was considered for statistical significance. Analysiswas conducted using Statistical Package for Social Sciences (SPSS, v17.0) software. 313 cardiologists were surveyed. The response rate was 29.7% (93/ 313) overall. Cardiologists' mean age was 42.6 ± 11.4 years old. 36 (38.7%) of them were echocardiography specialists and 30 (32.3%) were aortic stenosis specialists. 35 (37.6%) cardiologists worked in a teaching hospital, 32 (34.4%) in a general hospital, and 26 (26%) have a nonhospital activity.

BackgroundExercise testing is indicated in the evaluation of asymptomatic patients with severe aortic stenosis. Althought, « limited breathlessness » is a subjective symptom, difficult to evaluate for physicians, but it is the corner stone of the decision process to address the patient to the surgeon. The cardiopulmonary exercise-testing might help to distinguish ‘false’ asymptomatic patients to true by showing objective alteration in aerobic capacity.MethodsFrom December 2012 to September 2013, 21 asymptomatic patients (mean age 61+/-18 years, 52% men) with aortic stenosis defined by peak aortic jet velocity > 3m/s and preserved left ventricular ejection fraction (50%) were recruited. All patients were prospectively submitted to exercise stress echocardiography, cardiopulmonary exercise-testing and measurement of plasma NT-proBNP.ResultsAll patients underwent the double exercise protocole with no complication. The average mean oxygen consumption at peak exercise (VO2peak) was 21.1+/–7.3ml/kg/min, 84+/–18% predicted value). 11 (52%) patients had unexpected poor aerobic capacity, i.e. VO2peak 85% of the predicted value had any alteration of the oxygen pulse. None of the usual markers of poor prognosis in asymptomatic patients with aortic stenosis was significally associated with low aerobic capacity.ConclusionCardiopulmonary exercise-testing could be useful to determine a group of asymptomatic patients with aortic stenosis presenting an alteration of their functionnal capacity. This alteration of the oxygen consumption was not predicted by any of the markers actually used to risk stratification, especially not by the simple exercise-test criteria or the evaluation of the limited breathlessness by the NYHA score. A prospective follow-up of theese patients is required to determine if the alteration of the aerobic capacity in this population is associated with a poor prognosis.