Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis

Autori: Duk-Hyun Kang, M.D., Ph.D., Sung-Ji Park, M.D., Ph.D., Seung-Ah Lee, M.D., Sahmin Lee, M.D., Ph.D., Dae-Hee Kim, M.D., Ph.D., Hyung-Kwan Kim, M.D., Ph.D., Sung-Cheol Yun, Ph.D., Geu-Ru Hong, M.D., Ph.D., Jong-Min Song, M.D., Ph.D., Cheol-Hyun Chung, M.D., Ph.D., Jae-Kwan Song, M.D., Ph.D., Jae-Won Lee, M.D., Ph.D., and Seung-Woo Park, M.D., Ph.D.
Journal: N Engl J Med
Data Publication : 2020;382:111-119
DOI1: https://www.nejm.org/doi/10.1056/NEJMoa1912846

The timing and indications for surgical intervention in asymptomatic patients with severe aortic stenosis remain controversial.

In a multicenter trial, we randomly assigned 145 asymptomatic patients with very severe aortic stenosis (defined as an aortic-valve area of ≤0.75 cm2 with either an aortic jet velocity of ≥4.5 m per second or a mean transaortic gradient of ≥50 mm Hg) to early surgery or to conservative care according to the recommendations of current guidelines. The primary end point was a composite of death during or within 30 days after surgery (often called operative mortality) or death from cardiovascular causes during the entire follow-up period. The major secondary end point was death from any cause during follow-up.

In the early-surgery group, 69 of 73 patients (95%) underwent surgery within 2 months after randomization, and there was no operative mortality. In an intention-to-treat analysis, a primary end-point event occurred in 1 patient in the early-surgery group (1%) and in 11 of 72 patients in the conservative-care group (15%) (hazard ratio, 0.09; 95% confidence interval [CI], 0.01 to 0.67; P=0.003). Death from any cause occurred in 5 patients in the early-surgery group (7%) and in 15 patients in the conservative-care group (21%) (hazard ratio, 0.33; 95% CI, 0.12 to 0.90). In the conservative-care group, the cumulative incidence of sudden death was 4% at 4 years and 14% at 8 years.

Among asymptomatic patients with very severe aortic stenosis, the incidence of the composite of operative mortality or death from cardiovascular causes during the follow-up period was significantly lower among those who underwent early aortic-valve replacement surgery than among those who received conservative care. (Funded by the Korean Institute of Medicine; RECOVERY ClinicalTrials.gov number, NCT01161732. opens in new tab.)

PONV: a problem of inhalational anaesthesia?

Autori: Apfel CC, Stoecklein K, Lipfert P.
Journal: Best Pract Res Clin Anaesthesiol
Data Publication : 2005 Sep;19(3):485-500
DOI1: https://doi.org/10.1097/j.pain.0000000000001639