Elsevier

The Annals of Thoracic Surgery

Volume 86, Issue 6, December 2008, Pages 1781-1789
The Annals of Thoracic Surgery

Original article
Adult cardiac
Survival Benefit of Aortic Valve Replacement in Patients With Severe Aortic Stenosis With Low Ejection Fraction And Low Gradient With Normal Ejection Fraction

https://doi.org/10.1016/j.athoracsur.2008.08.008Get rights and content

Background

Aortic stenosis (AS) is becoming increasingly common with the aging population. Many of these patients have reduced left ventricular (LV) ejection fractions (EF) or low transvalvular gradients resulting in reluctance to offer aortic valve replacement (AVR).

Methods

Our echocardiographic database for the period of 1993 to 2003 was screened for severe AS (aortic valve area [AVA] ≤ 0.8 cm2) with LVEF 0.35 or less or a mean transvalvular gradient of 30 mm Hg or less. Chart reviews were performed for clinical, pharmacologic, and surgical details. Survival data were obtained from the Social Security Death Index and analysis was performed using Kaplan-Meier, Cox regression, sensitivity, and propensity score analysis.

Results

Of the 740 patients with severe AS, 194 (26%) had severe LV dysfunction defined as EF 0.35 or less and 168 (23%) a mean transvalvular gradient of 30 mm Hg or less. Low ejection fraction was not a prerequisite for a low gradient. The Univariate predictors of higher mortality in both groups included higher age, lower ejection fraction, renal insufficiency, and lack of aortic valve replacement. Lack of aortic valve replacement was a strong predictor of mortality after adjusting for 18 clinical, echocardiographic, and pharmacologic variables. There were 72 patients with EF 0.20 or less, of whom 18 had AVR, which was associated with a large survival benefit similar to the entire cohort. In the 52 patients with EF 0.55 or less and mean gradient less than 30 mm Hg, the 5-year survival with AVR was 90% compared with 20% without AVR (p < 0.0001) which was supported by propensity score analysis as well.

Conclusions

Severe LV dysfunction or a low transvalvular gradient is seen in about a quarter of patients with severe AS and there is a reluctance to offer AVR in these patients. Aortic valve replacement is associated with a large mortality benefit in these patients.

Section snippets

Patient Population

This retrospective cohort study from a large university medical center was approved by our local institutional review board, which waived the need for patient consent because of the retrospective study nature. The echocardiographic database was searched for patients with severe aortic stenosis defined as a valve area less than or equal to 0.8 cm2. This yielded a total of 740 patients. Of these, 194 patients had an LVEF of 0.35 or less and 168 (23%) had a mean transvalvular gradient of 30 mm Hg

Results

To retain clarity, the results are presented in two sections. These include: (A) severe AS patients with LVEF 0.35 or less; and (B) severe AS patients with transaortic mean gradients 30 mm Hg or less.

Our Findings

Our study shows that low EF and low valvular gradient despite normal EF are common in the setting of severe AS, occurring in 26% and 7% of the patients, respectively. There is also a reluctance to offer surgery in these patients with an AVR rate of only 30% despite a large survival benefit. The survival benefit is supported by both sensitivity and propensity score analysis, which are the best available tools to analyze treatment effects in observational data. As a randomized study in this

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