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Original research
Management of patients with severe aortic stenosis in the TAVI-era: how recent recommendations are translated into clinical practice
  1. Alexander Lauten1,
  2. Tanja K Rudolph2,
  3. David Messika-Zeitoun3,
  4. Jeetendra Thambyrajah4,
  5. Antonio Serra5,
  6. Eberhard Schulz6,
  7. Norbert Frey7,
  8. Jiri Maly8,9,
  9. Marco Aiello10,
  10. Guy Lloyd11,
  11. Alessandro Santo Bortone12,
  12. Alberto Clerici13,
  13. Georg Delle-Karth14,
  14. Johannes Rieber15,
  15. Ciro Indolfi16,
  16. Massimo Mancone17,
  17. Loic Belle18,
  18. Martin Arnold19,
  19. Berto J Bouma20,
  20. Matthias Lutz7,
  21. Cornelia Deutsch21,
  22. Jana Kurucova22,
  23. Martin Thoenes23,
  24. Peter Bramlage21 and
  25. Richard Paul Steeds24
  1. 1Department for Cardiology, Helios Clinic, Erfurt, Germany
  2. 2Department of Cardiology, Hear and Diabetes Center Bad Oeynhausen, Ruhr-University of Bochum, Bad Oeynhausen, Germany
  3. 3University of Ottawa Heart Institute, Ottawa, Ontario, Canada
  4. 4James Cook University Hospital, Middlesbrough, UK
  5. 5Interventional Cardiology Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain
  6. 6Cardiology Department, AKH Celle, Celle, Niedersachsen, Germany
  7. 7Department of Cardiology and Angiology, University of Kiel, Kiel, Schleswig-Holstein, Germany
  8. 8Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
  9. 9Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University, Prague, Czech Republic
  10. 10Department of Cardiothoracic Surgery, Foundation IRCCS Policlinico S.Matteo, Pavia, Italy
  11. 11St Bartholomew's Hospital, London, UK
  12. 12University of Bari, Bari, Puglia, Italy
  13. 13University of Turin, Turin, Piemonte, Italy
  14. 144th Medical Department, Hietzing Hospital, Vienna, Austria
  15. 15Herzkatheterlabor Nymphenburg and Department of Cardiology, University of Munich, Munich, Bayern, Germany
  16. 16Division of Cardiology and URT CNR of IFC, University Magna Graecia, Catanzaro, Calabria, Italy
  17. 17Sapienza University of Rome, Rome, Italy
  18. 18Centre Hospital d’Annecy, Annecy, France
  19. 19Department of Cardiology, University Hospital Erlangen, Erlangen, Bayern, Germany
  20. 20University of Amsterdam, Amsterdam, Netherlands
  21. 21Institut für Pharmakologie und Präventive Medizin GmbH, Cloppenburg, Germany
  22. 22Edwards Lifesciences, Prague, Czech Republic
  23. 23Edwards Lifesciences, Nyon, Switzerland
  24. 24Queen Elizabeth Hospital & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
  1. Correspondence to Dr Peter Bramlage; peter.bramlage{at}


Objective Approximately 3.4% of adults aged >75 years suffer from aortic stenosis (AS). Guideline indications for aortic valve replacement (AVR) distinguish between patients with symptomatic and asymptomatic severe AS. The present analysis aims to assess contemporary practice in the treatment of severe AS across Europe and identify characteristics associated with treatment decisions, namely denial of AVR in symptomatic patients and assignment of asymptomatic patients to AVR.

Methods Participants of the prospective, multinational IMPULSE database of patients with severe AS were grouped according to AS symptoms, and stratified into subgroups based on assignment to/denial of AVR.

Results Of 1608 symptomatic patients, 23.8% did not undergo AVR and underwent medical treatment. Denial was independently associated with multiple factors, including severe frailty (p=0.024); mitral (p=0.002) or tricuspid (p=0.004) regurgitation grade III/IV, and the presence of renal impairment (p=0.017). Of 392 asymptomatic patients, 86.5% had no prespecified indication for AVR. Regardless, 36.3% were assigned to valve replacement. Those with an indexed aortic valve area (AVA; p=0.045) or left ventricular ejection fraction (LVEF; p<0.001) below the study median; or with a left ventricular end systolic diameter above the study median (p=0.007) were more likely to be assigned to AVR.

Conclusions There may be considerable discrepancies between guideline-based recommendations and clinical practice decision-making in the treatment of AS. It appears that guidelines may not fully capture the complete clinical spectrum of patients with AS. Thus, there is a need to find ways to increase their acceptance and the rate of adoption.

  • aortic valve stenosis
  • transcatheter aortic valve replacement
  • cardiac surgical procedures

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  • Contributors All authors have participated in the work. RPS, DM-Z, NF, JK, MT and PB were involved in the conception and design of the project. AL and PB drafted the manuscript and all other authors revised the article for important intellectual content. All authors gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy.

  • Funding This work was supported with a research grant provided by Edwards Lifesciences (Nyon, Switzerland) to the Institute for Pharmacology and Preventive Medicine (IPPMed), Cloppenburg, Germany.

  • Competing interests Peter Bramlage received research funding from Edwards Lifesciences, Nyon, Switzerland. Norbert Frey, Rick Steeds and David Messika-Zeitoun have received honoraria for advisory board meetings and Tanja Rudolph speakers’ honoraria from Edwards Lifesciences. The institutions of these three and those of the remaining authors representing study centres have received funding for employing a study nurse.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the independent ethics review board at each participating institution and carried out in accordance with the Declaration of Helsinki.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available from the corresponding author upon reasonable request.

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