scholarly journals Early Aortic Valve Replacement vs. Conservative Management in Asymptomatic Severe Aortic Stenosis Patients With Preserved Ejection Fraction: A Meta-Analysis

2021 ◽  
Vol 7 ◽  
Author(s):  
Tan Yuan ◽  
Yi Lu ◽  
Chang Bian ◽  
Zhejun Cai
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Aortic Valve Replacement ◽  
Conservative Management ◽  
Severe Aortic Stenosis ◽  
Preserved Ejection Fraction ◽  
Cardiac Mortality ◽  
Asymptomatic Patients ◽  
All Cause Mortality

Background: Aortic stenosis (AS) is the most common valvular disease in developed countries. Until now, the specific timing of intervention for asymptomatic patients with severe aortic stenosis and preserved ejection fraction remains controversial.Methods: A systematic search of four databases (Pubmed, Web of science, Cochrane library, Embase) was conducted. Studies of asymptomatic patients with severe AS or very severe AS and preserved left ventricular ejection fraction underwent early aortic valve replacement (AVR) or conservative care were included. The end points included all-cause mortality, cardiac mortality, and non-cardiac mortality.Results: Four eligible studies were identified with a total of 1,249 participants. Compared to conservative management, patients who underwent early AVR were associated with lower all-cause mortality, cardiac mortality, and non-cardiac mortality rate (OR 0.16, 95% CI 0.09–0.31, P < 0.00001; OR 0.12, 95% CI 0.02–0.62, P = 0.01; OR 0.36, 95% CI 0.21–0.63, P = 0.0003, respectively).Conclusions: Early AVR is preferable for asymptomatic severe AS patients with preserved ejection fraction.

480Right ventricular dysfunction is associated with late mortality in severe aortic stenosis: results from a multi-centre outcome study in patients undergoing aortic valve replacement

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Rigolli ◽  
T A Musa ◽  
T A Treibel ◽  
M Loudon ◽  
V S Vassiliou ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Severe Aortic Stenosis ◽  
Term Survival ◽  
Early Stages ◽  
All Cause Mortality ◽  
Rv Function

Abstract Background The right ventricle (RV) is relatively understudied and often not routinely assessed in aortic stenosis (AS). However, there are several potential reasons for its importance. RV function is sensitive to left-sided afterload changes which can result in pulmonary hypertension (PH) in severe AS. PH is also a recognised predictor of poor prognosis in AS, but RV afterload and function can be difficult to assess. Cardiovascular magnetic resonance (CMR) may reveal unrecognised RV dysfunction and simultaneously evaluate other prognostic markers in AS. Purpose To investigate preoperative RV function assessed by CMR in severe AS and its association with mortality after aortic valve replacement (AVR). Methods 674 severe AS patients listed for either surgical or percutaneous AVR at six cardiothoracic centres underwent preoperative CMR (for ventricular function, mass and scar) along with echocardiography for valve severity. Scans were core-lab analysed for LV and RV volumes, function and scar quantification. Eight patients were excluded due to inadequate RV image quality for a total of 666 patients finally included. All-cause mortality was tracked for a minimum of 2 years after AVR. Results 107 (16%) of severe AS undergoing invasive AVR had a RV ejection fraction (RVEF) <55%. CMR detected overt RV dysfunction (RVEF <50%) in 61 (9%) patients. During a median 3.6 years follow-up, 145 (22%) patients died. Baseline RV dysfunction was the most powerful predictor of all-cause mortality (hazard ratio [HR] 2.5, 95% CI 1.6–3.9, p<0.0001). RV function was independent from other clinical characteristics but associated with signs of LV maladaptation (LV ejection fraction [LVEF] and late gadolinium enhancement [LGE]). The strongest Cox multivariable model for all-cause mortality accounted for RV dysfunction, age and LGE (adjusted HRs 1.7, 1.1, 2.2, respectively). Even early stages of pre-procedural RV dysfunction (RVEF 45–50%) were associated with reduced long-term survival. Cox and Kaplan-Meier for all-cause death Conclusion One out of 6 patients with severe AS undergoing valve replacement manifests a reduction in RV function detectable by CMR. Those with RV dysfunction (RVEF<50%) have a 2.5-fold increase in all-cause mortality after AVR at 3.6 years. Whilst RV dysfunction is associated with LV maladaptation (LGE, LVEF), it is a powerful independent factor associated with all-cause mortality and impacts survival even at early stages. Thus, the RV appears to be important in cardiac adaptation to AS and longevity after AS intervention. Acknowledgement/Funding British Heart Foundation and National Institute of Health Research

scholarly journals Propensity score-matched analysis of patients with severe aortic stenosis undergoing surgical aortic valve replacement

Open Heart ◽  
2019 ◽  
Vol 6 (1) ◽  
pp. e000992 ◽  
Author(s):  
Shiro Miura ◽  
Takehiro Yamashita ◽  
Michiya Hanyu ◽  
Hiraku Kumamaru ◽  
Shinichi Shirai ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Propensity Score ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Cardiovascular Events ◽  
Severe Aortic Stenosis ◽  
Surgical Aortic Valve Replacement ◽  
Asymptomatic Patients ◽  
All Cause Mortality ◽  
Baseline Characteristics

ObjectiveSevere aortic stenosis (AS) is one of the most serious valve conditions. Patient demography and the aetiology of AS have substantially changed in the past several decades along with a drastic improvement of surgical aortic valve replacement (SAVR) and its associated procedures. Contemporary patients with severe AS have multiple comorbidities and live much longer. We aimed to elucidate the treatment effects of SAVR on long-term outcome in propensity score (PS)-matched and the entire patient populations.MethodsWe retrospectively reviewed 570 patients with severe AS defined as an aortic valve area of 1.0 cm2 or less. Systemic differences in 39 baseline characteristics between non-SAVR and SAVR groups were adjusted using PS matching method. The endpoints included all-cause mortality and cardiovascular events that included heart failure, non-fatal stroke, syncope and acute coronary syndrome.ResultsOverall, 55% of the entire population (mean age 78 years; males 41%) were symptomatic. During 3.9 years of the median follow-up, 210 (36%) patients underwent SAVR and 231 (41%) died. Cumulative incidences of mortality and both mortality and cardiovascular events were significantly higher in the non-SAVR group than in the other group (p<0.001, each). Among 101 PS-matched pairs, SAVR correlated with a lower mortality risk (HR 0.35; 95% CI 0.21 to 0.59; p<0.001)) and mortality and cardiovascular events combined (HR 0.62; 95% CI 0.42 to 0.92; p=0.02). However, survival difference between both groups was markedly smaller among asymptomatic patients in the subgroup of matched patients.ConclusionPatients with AS undergoing SAVR exhibit a lower incidence of all-cause mortality and major cardiovascular events than those not undergoing surgical interventions, even after the baseline characteristics are balanced by the PS matching. The correlation between SAVR and survival from cardiovascular events is less evident among asymptomatic patients.

Abstract 12459: Is Ejection Fraction <50% the Optimal Threshold for Referral for Valve Replacement in Patients With Severe Aortic Stenosis? Impact of Ejection Fraction on Post-Operative Outcome

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Jordi S Dahl ◽  
Mackram F Eleid ◽  
Hector Michelena ◽  
Christopher Scott ◽  
Rakesh Suri ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Valve Replacement ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Optimal Threshold ◽  
Volume Index ◽  
Asymptomatic Patients ◽  
All Cause Mortality

Introduction: In asymptomatic patients with severe aortic stenosis (SAS), left ventricular (LV) ejection fraction (EF) <50% is generally considered to be the threshold for referral for aortic valve replacement (AVR). Hypothesis: We investigated the importance of LVEF on long-term outcome after AVR in symptomatic and asymptomatic SAS patients and studied whether LVEF < 50% is the optimal threshold for referral for AVR. Methods and Results: We retrospectively identified 2017 patients with SAS (aortic valve area (AVA)<1cm2, mean aortic valve gradient ≥40 mm Hg, or indexed AVA <0.6 cm2/m2) who underwent surgical AVR from January 1995 to June 2009 at our institution. Patients were divided into 4 groups depending on preoperative LVEF (<50% in 300 (15%) patients, 50-59% in 331 (17%), 60-69% in 908 (45%), and ≥70% in 478 (24%)). The primary end-point was all-cause mortality. During follow-up of 5.3±4.4 years, 1056 (52%) died. Five-year mortality rate increased with decreasing LVEF (41% (n=106), LVEF<50%); 35% (n=98), LVEF 50-59%; 26% (n=192), LVEF 60-69%; 22% (n=90), LVEF≥70%, p<0.0001). Compared to patients with LVEF≥60%, patients with LVEF 50-59% had increased mortality (HR 1.58, p<0.001), with a similar risk increase in both symptomatic (HR=1.56, p<0.001) and asymptomatic patients (HR 1.58, p=0.006, Figure). In a Cox regression analysis corrected for standard risk factors, LV mass index, AVA, and stroke volume index, LVEF was predictive of all-cause mortality (HR=0.89 per 10%, p<0.001). When this multivariable analysis was repeated in the subset of 1333 patients with no history of coronary artery disease, LVEF was still associated with all-cause mortality (HR=0.90 per 10%, p=0.009). Conclusion: In patients with SAS undergoing AVR, patients with LVEF 50-59% have also increased mortality compared to patients with LVEF>60%, suggesting that a different LVEF threshold should be used when referring for AVR.

Clinical significance of energy loss index in patients with low-gradient severe aortic stenosis and preserved ejection fraction

2020 ◽  
Vol 21 (6) ◽  
pp. 608-615 ◽  
Author(s):  
Alexandre Altes ◽  
Anne Ringle ◽  
Yohann Bohbot ◽  
Océane Bouchot ◽  
Ludovic Appert ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Preserved Ejection Fraction ◽  
Cardiac Mortality ◽  
Cardiac Events ◽  
Loss Index

Abstract Aims  We hypothesized that among patients with low-gradient severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF), reclassification of AS severity as moderate by pressure recovery adjusted indexed aortic valve area (AVAi) = energy loss index (ELI), may identify a subgroup of patients with a better outcome. Methods and results  Three hundred and seventy-nine patients with low-gradient AS (defined by AVAi ≤ 0.6 cm2/m2 and mean aortic pressure gradient &lt; 40 mmHg) and preserved LVEF ≥50% were studied. Reclassification as moderate AS by ELI was defined as AVAi ≤0.6 cm2/m2 but with an ELI &gt;0.6 cm2/m2. Cardiac events [cardiac mortality and/or need for aortic valve replacement (AVR)] during follow-up were studied. One hundred and forty-eight patients (39%) were reclassified as moderate AS by ELI. Reclassification as moderate AS was independently associated with decreased body surface area, normal flow status, decreased left ventricular mass index, and left atrial volume index (all P &lt; 0.05). After adjustment for variables of prognostic interest, reclassification as moderate AS by ELI was associated with a considerable reduction of risk of cardiac events {adjusted hazard ratio (HR) 0.49 [95% confidence interval (CI) 0.33–0.72]; P &lt; 0.001}, need for AVR [adjusted HR 0.52 (95% CI 0.34–0.81); P = 0.004], and cardiac mortality [adjusted HR 0.46 (95% CI 0.22–0.98); P = 0.044]. Conclusion  In patients with low-gradient severe AS and preserved LVEF, calculation of ELI permits to reclassify almost 40% of patients as having moderate AS. These reclassified patients have a considerable reduction of the risk of cardiac events during follow-up. Calculation of ELI is useful for decision-making in patients with low-gradient severe AS and preserved ejection fraction.

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