Transcatheter Aortic Valve Implantation in Patients With Low-Flow, Low-Gradient Aortic Stenosis

Department of Internal Medicine I, University Heart Center Jena, Jena, Germany.
JACC. Cardiovascular Interventions (Impact Factor: 7.35). 05/2012; 5(5):552-9. DOI: 10.1016/j.jcin.2012.04.001
Source: PubMed


The purpose of this study was to evaluate the efficacy and outcome of transcatheter aortic valve implantation (TAVI) in patients with low-flow, low-gradient aortic stenosis (LG-AS).
Patients with LG-AS have a poor prognosis with medical treatment and a high risk for surgical aortic valve replacement.
Between January 2009 and June 2010, a total of 1,302 patients underwent TAVI for severe AS and were prospectively included in the multicenter German TAVI registry.
LG-AS was present in 149 patients (11.4%; mean age: 80.2 ± 6.3 years). In this subgroup, the EuroSCORE was significantly higher (26.8 ± 16.6 vs. 20.0 ± 13.3; p < 0.0001) compared with patients with high-gradient AS (HG-AS). The procedural success rate (LG-AS: 95.3% vs. HG-AS: 97.5%; p = 0.13) and the rate of TAVI-associated complications were comparable in both groups (new pacemaker: 27.0% vs. 28.1%; p = 0.76; cerebrovascular events: 3.4% vs. 3.1%, p = 0.83). However, post-operative low-output syndrome occurred more frequently in the LG-AS-group (LG-AS: 14.9% vs. HG-AS: 5.7%, p < 0.0001), and mortality at 30 days and 1 year was significantly higher in this subgroup (LG-AS: 12.8% and 36.9% vs. HG-AS: 7.4% and 18.1%; p < 0.001 and p < 0.0001, respectively). Post-operative New York Heart Association functional class improved, and self-assessed quality of life increased significantly, demonstrating a substantial benefit in the LG-AS group at 30 days and 1 year after TAVI.
In high-risk patients with LG-AS, TAVI is associated with a significantly higher mortality at 30 days and at 1 year. However, long-term survivors benefit from TAVI with functional improvement and a significantly increased quality of life. Therefore, in view of the poor prognosis with medical treatment, TAVI should be considered an option in high-risk patients with LG-AS.

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Available from: Ulrich Gerckens, Apr 05, 2014
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    • " high peri - and post - operative mortality of conventional valve replacement ( Levy et al . , 2008 ; Tribouilloy et al . , 2009 ) . TAVI might offer a viable treatment option for patients with LFLGAS , and a recent study by Lauten A et al . has shown its safety and positive clinical outcomes in long - term survivors in this subgroup of patients ( Lauten et al . , 2012 ) . However , to our knowledge , the hemodynamic and structural changes on LFLGAS patients after TAVI have not been extensively studied ."
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    ABSTRACT: Background and AimsTranscatheter aortic valve implantation (TAVI) is an established method for the treatment of high-risk patients with aortic stenosis (AS). The beneficial effects of TAVI in cardiac hemodynamics have been described in recent studies, but those investigations were mostly performed after an interval of more than 6 months following aortic valve implantation. The aim of this study is to investigate the acute and short-term alterations in hemodynamic conditions using the echocardiography outcomes in patients undergoing TAVI.Methods and ResultsA total of 60 patients (26 males, 34 females; age 84·7 ± 5·8) who underwent TAVI with CoreValve system were included in the study. Echocardiography was performed before hospital discharge and at 3 months follow-up. As expected, TAVI was associated with an immediate significant improvement in aortic valve area (AVA) (from 0·64 ± 0·16 cm2 to 1·67 ± 0·41 cm2, P-value<0·001) and mean gradient (from 51·9 ± 15·4 mmHg to 8·8 ± 3·8 mmHg, P-value<0·001). At 3-month follow-up, systolic LV function was augmented (EF: 50 ± 14% to 54 ± 11%, P-value = 0·024). Left ventricle (LV) mass and left atrium (LA) volume were significantly reduced (LV mass index from 126·5 ± 30·5 g m−2 to 102·4 ± 32·4 g m−2; LA index from 42·9 ± 17·3 ml m−2 to 33·6 ± 10·6 ml m−2; P-value<0·001 for both). Furthermore, a decrement in systolic pulmonary artery pressure (SPAP) from 47·5 ± 13·5 mmHg to 42·5 ± 11·2 mmHg, P-value = 0·02 was also observed. Despite the high incidence of paravalvular regurgitation (PVR) (80%), most of the patients presented mild or trace PVR and no significant progress of the regurgitation grade was seen after 3 months.Conclusion This study demonstrates that the beneficial effects of TAVI in cardiac function and hemodynamics occur already after a short period following aortic valve implantation.
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    Preview · Article · Apr 2012 · Journal of the American College of Cardiology
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    ABSTRACT: It is generally held that outcome for patients with valvular heart disease is largely determined by the contractility of the left and/or right ventricles. This innate force generation capability might become compromised when chronic severe hemodynamic overload injures the myocardium, impairing function and prognosis. In aortic stenosis (AS), impaired left ventricular (LV) ejection is in part predicated on reduced contractility and also upon excess afterload imposed by the stenotic valve as it causes obstruction to outflow (1-4). The property that dominates-excess afterload versus reduced contractility-in a given patient determines prognosis (2).
    Preview · Article · May 2012 · JACC. Cardiovascular Interventions
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