title: Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography.
abstract: OBJECTIVE
  This study investigated whether aortic valve replacement (AVR) is associated with improved survival in patients with severe low-flow/low-gradient aortic stenosis (LF/LGAS) without contractile reserve (CR) on dobutamine stress echocardiography (DSE).
  
  
  BACKGROUND
  Patients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial.
  
  
  METHODS
  Eighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area <or=1 cm(2), left ventricular ejection fraction <or=40%, mean pressure gradient [MPG] <or=40 mm Hg) without CR on DSE were enrolled. Absence of CR was defined as the absence of increase in stroke volume of >or=20% compared with the baseline value. Multivariable analysis and propensity scores were used to compare survival according to whether or not AVR was performed (n = 55).
  
  
  RESULTS
  Five-year survival was higher in AVR patients compared with medically managed patients (54 +/- 7% vs. 13 +/- 7%, p = 0.001) despite a high operative mortality of 22% (n = 12). An AVR was independently associated with lower 5-year mortality (adjusted hazard ratio from 0.16 to 5.21 varying with time [95% confidence interval: 0.12-3.16 to 0.21-8.50], p = 0.00026). In 42 propensity-matched patients, 5-year survival was markedly improved by AVR (65 +/- 11% vs. 11 +/- 7%, p = 0.019). Associated bypass surgery (p = 0.007) and MPG <or=20 mm Hg (p = 0.035) were independently predictive of operative mortality. Late survival after AVR (excluding operative death) was 69 +/- 8% at 5 years.
  
  
  CONCLUSIONS
  In patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.
authors.affiliation: Department of Cardiology, INSERM, ERI-12, Amiens and University Hospital Amiens, Amiens, France. tribouilloy.christophe@chu-amiens.fr
authors.forename: Christophe
authors.initials: C
authors.lastname: Tribouilloy
authors.forename: Franck
authors.initials: F
authors.lastname: Lévy
authors.forename: Dan
authors.initials: D
authors.lastname: Rusinaru
authors.forename: Pascal
authors.initials: P
authors.lastname: Guéret
authors.forename: Hélène
authors.initials: H
authors.lastname: Petit-Eisenmann
authors.forename: Serge
authors.initials: S
authors.lastname: Baleynaud
authors.forename: Yannick
authors.initials: Y
authors.lastname: Jobic
authors.forename: Catherine
authors.initials: C
authors.lastname: Adams
authors.forename: Bernard
authors.initials: B
authors.lastname: Lelong
authors.forename: Agnès
authors.initials: A
authors.lastname: Pasquet
authors.forename: Christophe
authors.initials: C
authors.lastname: Chauvel
authors.forename: Damien
authors.initials: D
authors.lastname: Metz
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Quéré
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Monin
mesh_terms: D000368:Aged; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D016001:Confidence Intervals; D025401:Echocardiography, Stress / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D006801:Humans; D008297:Male; D009200:Myocardial Contraction / Q000502:physiology*; D016017:Odds Ratio; D011184:Postoperative Period; D012307:Risk Factors; D013318:Stroke Volume / Q000502:physiology*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left / Q000502:physiology*