Key result
Resecting subaortic stenosis at gradients ≤40 mm Hg is linked to ~87% lower recurrence.
Why the study?
It remained uncertain whether early surgical resection of fixed subaortic stenosis before significant gradients occur can reduce recurrence or progression of aortic valve damage.
Does early transaortic resection (LVOT gradient ≤ 40 mm Hg) reduce recurrence and progressive aortic valve disease in patients with fixed subaortic stenosis compared to resection at higher gradients?
Cohort (n=75)
Does early transaortic resection (LVOT gradient ≤ 40 mm Hg) reduce recurrence and progressive aortic valve disease in patients with fixed subaortic stenosis compared to resection at higher gradients?
Absolute Event Rate: 0.87% vs 6.45%
p-value: p=0.002
Early surgical resection of fixed subaortic stenosis before the LVOT gradient exceeds 40 mm Hg significantly reduces the risk of recurrence and progressive aortic valve disease.
Supports resection at LVOT gradient ≤40 mm Hg in fixed subaortic stenosis; observational data leave open need for randomized confirmation.
OBJECTIVES: We sought to determine whether early resection can improve outcome in fixed subaortic stenosis. BACKGROUND: The diagnosis of subaortic stenosis (SAS) is often made before significant gradients occur. Whereas resection is the accepted treatment, it remains uncertain whether surgical intervention at this early stage can reduce the incidence of recurrence or influence the progression of aortic valve damage. METHODS: Follow-up was available for 75 of 83 consecutive patients operated on for fixed SAS; the average duration of follow-up was 6.7 years. The lesion was discrete in 68 patients (91%) and of a tunnel type in 7, with associated ventricular septal defect in 28 (37%). All underwent transaortic resection. RESULTS: There were no deaths. There were 18 recurrences of SAS in 15 patients (20%). Thirteen patients (17%) underwent 17 reoperations for recurrence or aortic valve disease. The cumulative hazard of recurrence was 8.9%, 16.1% and 29.4% +/- 2.3% (mean +/- SEM), and the hazard of events, including recurrence and reoperation, was 9.2%, 18.4% and 35.1% +/- 3.5% at 2, 5 and 10 years, respectively. Residual end-operative left ventricular outflow tract (LVOT) gradients (> 10 mm Hg, n = 8) and tunnel lesions were univariate predictors of recurrence (p = 0.0006 and p = 0.003, respectively). Multivariate predictors included higher preoperative LVOT gradient (p < 10(-4)) and younger patient age (p = 0.002). Only two recurrences (0.87 per 100 patient-years of follow-up) were noted in patients with a preoperative peak LVOT gradient < or = 40 mm Hg (n = 40), whereas higher gradients (n = 35) were associated with a greater than sevenfold recurrence rate (6.45 events per 100 patient-years, p = 0.002). The aortic valve required concomitant repair in 17 cases in the high gradient group (48.6%) but in only 8 in the low gradient group (20%, p = 0.018). Despite relief of the obstruction, progressive aortic regurgitation was noted at follow-up after 14 procedures in the high gradient group (40%) but after only 5 procedures in the low gradient group (12.5%, p = 0.014). CONCLUSIONS: The data suggest that surgical resection of fixed subaortic stenosis before the development of a significant (> 40 mm Hg) outflow tract gradient may prevent recurrence, reoperation and secondary progressive aortic valve disease.
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Brauner et al. (1997) conducted a cohort in Fixed subaortic stenosis (n=75). Preoperative peak LVOT gradient ≤ 40 mm Hg prior to surgical resection vs. Preoperative peak LVOT gradient > 40 mm Hg was evaluated on Recurrence of subaortic stenosis (p=0.002). Surgical resection of fixed subaortic stenosis with a preoperative gradient ≤40 mm Hg was associated with a lower recurrence rate than higher gradients (0.87 vs 6.45 events per 100 patient-years, P=0.002).
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