Comparison of outcome of higher versus lower transvalvular gradients in patients with severe aortic stenosis and low (<40%) left ventricular ejection fraction.

Division of Cardiology, Washington Hospital Center, Washington, District of Columbia, USA.
The American journal of cardiology (Impact Factor: 3.58). 01/2012; 109(7):1031-7. DOI: 10.1016/j.amjcard.2011.11.041
Source: PubMed

ABSTRACT 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 cm(2), 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/m(2), 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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    ABSTRACT: Low-flow, low-gradient (LF-LG) aortic stenosis (AS) may occur with depressed or preserved left ventricular ejection fraction (LVEF), and both situations are among the most challenging encountered in patients with valvular heart disease. In both cases, the decrease in gradient relative to AS severity is due to a reduction in transvalvular flow. The main challenge in patients with depressed LVEF is to distinguish between true severe versus pseudosevere stenosis and to accurately assess the severity of myocardial impairment. Paradoxical LF-LG severe AS despite a normal LVEF is a recently described entity that is characterized by pronounced LV concentric remodeling, small LV cavity size, and a restrictive physiology leading to impaired LV filling, altered myocardial function, and worse prognosis. Until recently, this entity was often misdiagnosed, thereby causing underestimation of AS severity and inappropriate delays for surgery. Hence, the main challenge in these patients is proper diagnosis, often requiring diagnostic tests other than Doppler echocardiography. The present paper proposes to review the diagnostic and therapeutic management specificities of LF-LG AS with and without depressed LV function.
    Journal of the American College of Cardiology 10/2012; · 14.09 Impact Factor
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    ABSTRACT: Objectives: To identify predictors of mortality, functional status and hemodynamical changes of patients undergoing TAVI for low flow/low gradient AS (LF/LG AS). Background: There is little published data regarding the outcomes of patients with LF/LG AS following transcatheter aortic valve implantation (TAVI). Methods: Sixty-eight patients with severe AS, left ventricular dysfunction (ejection fraction (EF) <35%) and low flow AS underwent TAVI. Patients were stratified according to the aortic mean pressure gradient (low gradient (LG); with Pmean ≤ 40 mmHg and high gradient (HG): Pmean >40 mmHg.) The baseline parameters and clinical outcomes were subsequently compared among the two groups. Cox proportional hazards were used to identify predictors of 6-month mortality. Results: There were 38 patients in the LG group and 30 patients in the HG group. There were no significant difference in 30-day mortality between the two groups. The 6-month and 1-year mortality, however, was 3.8-fold higher in the LG group than in the HG group (37.8 vs. 10.3%, p=0.01 and 37.8 vs 13.3%, respectively, p=0.01). Univariable predictors for 6-month mortality were: STS Score, aortic valve area and aortic mean pressure gradient. However, only STS Score (HR 1.08, 1.04-1.12, p<0.001) remained as independent predictor in the multivariable analysis. Six months after TAVI, hemodynamical (EF>50%) and clinical (NYHA class I) improvements were shown in both HG and LG groups. Conclusions: LF/LG AS does not influence procedural mortality after TAVI but exhibits a strong impact on 6-month and 1-year mortality. The survivors however, exhibit considerable hemodynamical and clinical improvements. Therefore, risk stratification and TAVI benefit should be weighted in every patient with LF/LG AS. © 2014 Wiley Periodicals, Inc.
    Catheterization and Cardiovascular Interventions 01/2014; · 2.51 Impact Factor
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    ABSTRACT: BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an alternative treatment of severe symptomatic aortic stenosis (AS) in patients with high operative risk. In spite of favorable entire results, long-term mortality of patients is high. HYPOTHESIS: The present study aims to identify independent preprocedural risk factors to improve risk stratification in these highly selected patients. METHODS: This prospective study included 202 consecutive patients with severe symptomatic AS and high operative risk (mean logistic European System for Cardiac Operative Risk Evaluation, 22 ± 17%; mean age, 79 ± 6 years; 107 female). Preprocedural comprehensive examinations were performed (laboratory, electrocardiography, echocardiography, cardiac catheterization). All patients received transfemoral or transaxillary TAVI with a CoreValve prosthesis (Medtronic, Minneapolis, MN). RESULTS: During a follow-up of 535 ± 333 days, 56 patients (28%) reached the primary study end point (all-cause mortality). Independent predictors of long-term mortality were as follows: hemoglobin <12.5 g/dL (hazard risk [HR], 3.62; 95% confidence interval [CI], 2.025-6.468; P < 0.001), aortic mean gradient ≤41 mm Hg (HR, 2.16; 95% CI, 1.272-3.655; P = 0.004), and left atrial diameter > 42 mm (HR, 3.09; 95% CI, 1.588-6.019; P = 0.001). Our risk-stratification model based on these independent predictors separated patients into 4 groups with high (74%), intermediate (37%), low (18%), and very low (3%) all-cause mortality. CONCLUSIONS: In patients undergoing TAVI, preprocedural assessment of hemoglobin, aortic mean gradient, and left atrial diameter provides independent prognostic information and therefore contributes to improved risk stratification in TAVI.
    Clinical Cardiology 02/2013; · 1.83 Impact Factor


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