Aortic Valve Replacement is Superior to Conservative Management in Low-Flow, Low-Gradient Aortic Stenosis independently of the presence of true severe stenosis - 21/03/19
, A. Dahou 1, I.G. Burwash 2, P.E. Bartko 3, J. Bergler-Klein 3, J. Mascherbauer 3, G. Mundigler 3, S. Orwat 4, H. Baumgartner 4, J. Cavalcante 5, H.B. Ribeiro 6, J. Rodes-Cabau 1, M.A. Clavel 1, P. Pibarot 1
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Résumé |
Background |
The survival benefit of surgical (SAVR) or transcatheter (TAVR) aortic valve replacement over conservative management (ConsRx) remains unclear in patients with low-flow, low-gradient (LFLG) aortic stenosis (AS).
Method |
476 LFLG AS patients (mean age 75±10 yo, 71% males, 71% classical and 29% paradoxical LFLG, aortic valve area=0.79±0.15cm2 and mean gradient=26±7mmHg) were prospectively recruited. Survival was studied using Kaplan-Meier curves. Inverse probability-of-treatment-weighting (IPW) was used to balance patients’ characteristics between AVR and ConsRx groups. Cox proportional hazards regression was used to corroborate the findings and study the benefit associated with of SAVR, TAVR (including transfemoral and transapical accesses).
Results |
During a median follow up of 32 months, 220 patients died and less than 5% were lost to follow up. AVR markedly reduced the risk of death (Fig. 1, Panel A). Interestingly, the benefit extended also to patients with pseudosevere AS (Fig. 1, Panel B). These results were consistent with non-weighted univariate and multivariate analyses. TAVR patients had significantly more comorbidities compared to ConsRx or SAVR patients, including older age, previous myocardial infarction, diabetes, renal failure, and more depressed left ventricular function as assessed by NT-proBNP (all with P<0.05); all of these factors independently associated with increased mortality. After adjustment for these comorbidities and AS severity, TAVR was associated with a lower risk of mortality compared to ConsRx (HR=0.40; 95%CI [0.22–0.71], P=0.002), and a similar risk compared to SAVR (HR=0.83, 95%CI [0.46–1.51], P=0.52). There was no interaction (P=0.93) between treatment and the pattern of LFLG (paradoxical vs classical) with mortality.
Conclusion |
SAVR and TAVR were associated with better survival compared to ConsRx in both classical and paradoxical LFLG AS patients. The benefit extended to those with pseudosevere AS.
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Vol 11 - N° 2
P. 246-247 - avril 2019 Retour au numéro
Article précédent
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