Valvular heart disease
Comparison of Outcome of Higher Versus Lower Transvalvular Gradients in Patients With Severe Aortic Stenosis and Low (<40%) Left Ventricular Ejection Fraction

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Left ventricular systolic dysfunction in patients with severe aortic stenosis (AS) is associated with poor outcome. This analysis was designed primarily to describe the clinical course of a large series of consecutive patients with severe AS and low ejection fraction (EF) (<40%) who, because of high surgical risk, were referred for transcatheter aortic valve implantation consideration. A cohort of 270 patients with severe AS and low EF (<40%) who were referred to participate in a clinical trial of transcatheter aortic valve implantation was studied. Clinical, hemodynamic, and periprocedural complications and follow-up mortality data were collected and compared between patients with low mean transvalvular gradients (≤40 mm Hg, n = 170 [63%]) and high transvalvular gradients (>40 mm Hg, n = 100 [37%]). Patients with low gradients were younger (mean age 79.8 ± 9.1 vs 83.8 ± 7.7 years, p <0.001) and had higher incidences of coronary artery disease and renal failure. Mean aortic valve area was larger (0.73 ± 0.23 vs 0.53 ± 0.18 cm2, p <0.001), while mean EF (26.4 ± 6.9% vs 30.5% ± 6.6%, p <0.001), cardiac output (3.7 ± 1.1 vs 4.1 ± 1.3 L/min, p = 0.04), and cardiac index (1.9 ± 0.5 vs 2.1 ± 0.6 L/min/m2, p = 0.04) were lower in patients with lower gradients compared to those with higher gradients, respectively. Mortality was higher in patients with low gradients (53.8%) at a mean follow-up of 151 days compared to those with high gradients (41%) at a mean follow-up of 256 days (p = 0.01). In conclusion, patients with severe AS and low EF with low transvalvular gradients are at higher risk for worse outcomes compared to patients with high transvalvular gradients. Surgery or transcatheter aortic valve implantation treatment and high baseline transvalvular gradient are associated with EF improvement.

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Methods

From April 2007 to December 2010, 890 consecutive patients with severe symptomatic AS, defined as aortic valve area <1 cm2 or aortic valve index <0.5 cm2/m2, who were referred for participation in a randomized TAVI trial (Placement of Aortic Transcatheter Valves [PARTNER]) were prospectively entered into a dedicated database and thus considered for this analysis. All patients were screened and gave written consent for the study. Those with severe AS (aortic valve area <1 cm2 or aortic valve

Results

Baseline clinical characteristics of low- and high-gradient patients are listed in Table 1. Those with low gradients were younger by 4 years (p <0.001) and more often had coronary heart disease, as evidenced by more previous myocardial infarctions (p = 0.01) and coronary bypass surgery (p <0.001). They also more often had renal insufficiency (p = 0.03).

Table 2 compares the echocardiographic and hemodynamic measurements of the 2 groups. Aortic valve area was larger (p <0.001), while the EF and

Discussion

Our study confirms the limited life expectancy of patients (overall mortality of 50% at 2 years) who present with severe AS and depressed left ventricular function, who are at high risk for SAVR. In particular, the results of the study demonstrate the adverse prognostic implications of patients presenting with low transvalvular gradients (<40 mm Hg), who experienced an even higher mortality rate compared to patients with higher transvalvular gradients.

A similar adverse prognostic impact of a

References (19)

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