HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anees Razzouk Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pai, R. G. Articles by Razzouk, A. Search for Related Content PubMed PubMed Citation Articles by Pai, R. G. Articles by Razzouk, A. Related Collections Valve disease Related Article

---

Original Articles: 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

^a Division of Cardiology, Loma Linda University Medical Center, Loma Linda, California
^b Division of Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, California

Accepted for publication August 4, 2008.

^_* Address correspondence to Dr Pai, Division of Cardiology, Loma Linda University School of Medicine, 11234 Anderson Street, #4414, Loma Linda, CA 92354 (Email: rpai{at}llu.edu).

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.

Related Article

Invited Commentary

and
Ann. Thorac. Surg. 86: 1789-1790. [Full Text]

This article has been cited by other articles:

				J. G. Dumesnil, P. Pibarot, and B. Carabello Paradoxical low flow and/or low gradient severe aortic stenosis despite preserved left ventricular ejection fraction: implications for diagnosis and treatment Eur. Heart J., September 8, 2009; (2009) ehp361v1. [Abstract] [Full Text] [PDF]

				V. Delgado, L. F. Tops, R. J. van Bommel, F. van der Kley, N. A. Marsan, R. J. Klautz, M. I.M. Versteegh, E. R. Holman, M. J. Schalij, and J. J. Bax Strain analysis in patients with severe aortic stenosis and preserved left ventricular ejection fraction undergoing surgical valve replacement Eur. Heart J., September 2, 2009; (2009) ehp351v1. [Abstract] [Full Text] [PDF]

				M. E. Halkos, E. P. Chen, E. L. Sarin, P. Kilgo, V. H. Thourani, O. M. Lattouf, J. D. Vega, C. D. Morris, T. Vassiliades, W. A. Cooper, et al. Aortic valve replacement for aortic stenosis in patients with left ventricular dysfunction. Ann. Thorac. Surg., September 1, 2009; 88(3): 746 - 751. [Abstract] [Full Text] [PDF]

				E. L. Hannan, Z. Samadashvili, S. J. Lahey, C. R. Smith, A. T. Culliford, R. S.D. Higgins, J. P. Gold, and R. H. Jones Aortic Valve Replacement for Patients With Severe Aortic Stenosis: Risk Factors and Their Impact on 30-Month Mortality. Ann. Thorac. Surg., June 1, 2009; 87(6): 1741 - 1749. [Abstract] [Full Text] [PDF]

				J. G. Dumesnil and P. Pibarot Invited Commentary Ann. Thorac. Surg., December 1, 2008; 86(6): 1789 - 1790. [Full Text] [PDF]