Classical low-flow aortic stenosis with very low left ventricular ejection fraction or no flow reserve: Do they benefit from aortic valve replacement? - 21/03/19
, A. Dahou 1, P.E. Bartko 2, I.G. Burwash 3, J. Bergler-Klein 2, J. Mascherbauer 2, S. Orwat 4, G. Mundigler 2, H. Baumgartner 4, H.B. Ribeiro 5, J. Rodes-Cabau 1, J. Cavalcante 6, M.A. Clavel 1, P. Pibarot 1
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Résumé |
Background |
In patients with classical low-flow, low-gradient (CLF i.e. with left ventricular ejection fraction [LVEF]<50%) aortic stenosis (AS), the presence of very low left ventricular ejection fraction (LVEF) i.e.≤25% or the absence of flow reserve (FR) raise uncertainties regarding true stenosis severity and benefit-risk ratio challenging aortic valve replacement (AVR) decision-making.
Objective |
To study the survival benefit of AVR in AS patients with LVEF≤25% or no FR.
Methods |
A total of 343 AS patients with CLF-AS were prospectively recruited. Age, sex, True AS severity, LVEF and various comorbidity data were entered in a logistic regression model to calculate a propensity score for AVR (c-statistics=0.84 to predict AVR versus conservative management). After inverse propensity of treatment weighting (IPW), baseline characteristics were well-balanced between AVR and no AVR patients. The survival benefit of AVR was then studied according to the presence of LVEF≤25% and or to the presence of CR (in 205 patients who underwent dobutamine stress assessment). Cox proportional hazards regression adjusting for age, sex, true severe AS (TSAS) and the EuroSCORE was used in the non-weighted observations to corroborate the findings in IPW.
Results |
After AVR, survival was comparable between:.
–patients with LVEF≤25% vs. LVEF>25% (Figure 1, Panel A);
–in patients with vs. without FR (Figure 1, Panel B).
Furthermore, AVR was associated with improved survival in patients with LVEF≤25% and in patients with no FR. Moreover, LVEF≤25% or FR had no impact on mortality in the overall cohort in multivariate analysis (P=0.19 and P=0.31 respectively). AVR, particularly transfemoral transcatheter AVR associated with a markedly reduced adjusted risk of death, and no interaction was found with LVEF≤25 (P=0.44) or with FR (0.84).
Conclusion |
In this prospective series of CLF-AS, patients with very low LVEF or with no flow reserve benefit from AVR.
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Vol 11 - N° 2
P. 256 - avril 2019 Retour au numéro
Article précédent
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