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.

4th Medical Department Hietzing Hospital Vienna Austria

Cardiology Department AKH Celle Celle Niedersachsen Germany

Centre Hospital d'Annecy Annecy France

Department for Cardiology Helios Clinic Erfurt Germany

Department of Cardiology and Angiology University of Kiel Kiel Schleswig Holstein Germany

Department of Cardiology Hear and Diabetes Center Bad Oeynhausen Ruhr University of Bochum Bad Oeynhausen Germany

Department of Cardiology University Hospital Erlangen Erlangen Bayern Germany

Department of Cardiothoracic Surgery Foundation IRCCS Policlinico S Matteo Pavia Italy

Department of Cardiovascular Surgery 2nd Faculty of Medicine Charles University Prague Czech Republic

Department of Cardiovascular Surgery Institute for Clinical and Experimental Medicine Prague Czech Republic

Division of Cardiology and URT CNR of IFC University Magna Graecia Catanzaro Calabria Italy

Edwards Lifesciences Nyon Switzerland

Edwards Lifesciences Prague Czech Republic

Herzkatheterlabor Nymphenburg and Department of Cardiology University of Munich Munich Bayern Germany

Institut für Pharmakologie und Präventive Medizin GmbH Cloppenburg Germany

Interventional Cardiology Unit Hospital de la Santa Creu i Sant Pau Barcelona Catalunya Spain

James Cook University Hospital Middlesbrough UK

Queen Elizabeth Hospital and Institute of Cardiovascular Sciences University of Birmingham Birmingham UK

Sapienza University of Rome Rome Italy

St Bartholomew's Hospital London UK

University of Amsterdam Amsterdam Netherlands

University of Bari Bari Puglia Italy

University of Ottawa Heart Institute Ottawa Ontario Canada

University of Turin Turin Piemonte Italy

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