Causes of death in severe aortic stenosis according to symptoms and initial treatment strategies in the TAVR era

Abstract Background There are no studies evaluating mortality and causes of death in severe aortic stenosis (AS) according to symptoms and treatment strategies in contemporary transcatheter aortic valve replacement era. Methods Among 3369 consecutive patients with severe AS in the CURRENT AS registry-2, we comprehensively evaluated mortality rates and causes of death in patients with severe AS according to symptoms and treatment strategies. Results There were 2011 patients with symptomatic severe AS [initial aortic valve replacement (AVR) strategy: N = 1410, and conservative strategy: N = 601] and 1358 patients with asymptomatic severe AS (initial AVR strategy: N = 332, and conservative strategy: N = 1026). During median 2.2 years follow-up, all-cause death occurred in 736 patients, including 297 patients with cardiac death (40.4% of total mortality), 44 patients with vascular death (6.0% of total mortality), and 351 patients with non-cardiovascular death (47.7% of total mortality). In patients with cardiac death, the most common cause was heart failure (22.6% of total mortality), and the second most common cause was sudden death (11.7% of total mortality). In patients with non-cardiovascular death, the most common cause was infection (19.3% of total mortality), and the second most common cause was malignancy (12.2% of total mortality). Cumulative 3-year incidence of all-cause death (proportions of cardiac and non-cardiovascular death) was 22.9% (30.2% and 58.2% of total mortality) in symptomatic severe AS with initial AVR strategy, 53.1% (56.1% and 35.6% of total mortality) in symptomatic severe AS with conservative strategy, 15.5% (23.7% and 68.4% of total mortality) in asymptomatic severe AS with initial AVR strategy, and 24.7% (35.7% and 46.9% of total mortality) in asymptomatic severe AS with conservative strategy. Conclusions There was a great difference in mortality and causes of death according to symptoms and treatment strategies in severe AS. Non-cardiovascular death was one of the major components of death in patients who were managed not only invasively but also conservatively.