Abstract

Introduction: Aortic stenosis is the most common valvular heart disease and is managed by aortic valve replacement (AVR) procedures. Comorbid conditions may impact survival after AVR. Methods: We evaluated risk factors for all-cause mortality after AVR in the Veterans Affairs (VA) healthcare system for individuals with an AVR between January 1 st 2007 and December 31 st 2017, with National Death Index mortality data through December 31 st , 2020. Clinical diagnoses and procedures were established by International Classifications of Disease (ICD) and Current Procedural Terminology (CPT) codes both in the VA and the Center for Medicare and Medicaid Services. Hazard rates for the primary outcome of all-cause mortality were calculated using a cox proportional hazards model adjusted for age at AVR, sex, and prevalent clinical risk factors (heart failure [HF], obesity, type 2 diabetes [T2D], and myocardial infarction [MI]). Results: There were 7,984,029 individuals seen regularly at the VA between 2007 and 2017. Within this group, there were 783,772 (9.8%) individuals with an established diagnosis of AS without prior valve replacement with a median (interquartile [IQR]) age of 73.5 [67.4-80.3] years, and 98% male. Between 2007-2017, 66,931 individuals had an AVR with median [IQR] age 72.8 [66.6-79.3] years, 98% male. Of the individuals with an AVR, 24,253 (36.2%) died prior to the end of follow up, with a median [IQR] time to death of 3.3 [2.8-5.3] years. At the time of valve replacement, there were 16,301 (24%) diagnoses of CKD, 11,916 (18%) diagnoses of HF, 21,575 (32%) diagnoses of T2D, and 4,211 (6%) diagnoses of prior MI. In a multivariable model, with adjustment for age, sex, and all clinical risk factors, a prevalent HF diagnosis portended the highest risk of all-cause mortality after AVR (HR 1.57 [1.52-1.62], p < 0.001), followed by T2D (HR 1.13 [1.09-1.16], p < 0.001), CKD (HR 1.11 [1.08-1.15], p < 0.001), and MI (1.05 [0.99-1.11], p = 0.06). Conclusions: Common clinical comorbidities including HF, CKD, and T2D, but not MI independently increase the risk of all-cause mortality after AVR.