title: Comparison of outcome of higher versus lower transvalvular gradients in patients with severe aortic stenosis and low (<40%) left ventricular ejection fraction.
abstract: Left ventricular systolic dysfunction in patients with severe aortic stenosis (AS) is associated with poor outcome. This analysis was designed primarily to describe the clinical course of a large series of consecutive patients with severe AS and low ejection fraction (EF) (<40%) who, because of high surgical risk, were referred for transcatheter aortic valve implantation consideration. A cohort of 270 patients with severe AS and low EF (<40%) who were referred to participate in a clinical trial of transcatheter aortic valve implantation was studied. Clinical, hemodynamic, and periprocedural complications and follow-up mortality data were collected and compared between patients with low mean transvalvular gradients (≤40 mm Hg, n = 170 [63%]) and high transvalvular gradients (>40 mm Hg, n = 100 [37%]). Patients with low gradients were younger (mean age 79.8 ± 9.1 vs 83.8 ± 7.7 years, p <0.001) and had higher incidences of coronary artery disease and renal failure. Mean aortic valve area was larger (0.73 ± 0.23 vs 0.53 ± 0.18 cm(2), p <0.001), while mean EF (26.4 ± 6.9% vs 30.5% ± 6.6%, p <0.001), cardiac output (3.7 ± 1.1 vs 4.1 ± 1.3 L/min, p = 0.04), and cardiac index (1.9 ± 0.5 vs 2.1 ± 0.6 L/min/m(2), p = 0.04) were lower in patients with lower gradients compared to those with higher gradients, respectively. Mortality was higher in patients with low gradients (53.8%) at a mean follow-up of 151 days compared to those with high gradients (41%) at a mean follow-up of 256 days (p = 0.01). In conclusion, patients with severe AS and low EF with low transvalvular gradients are at higher risk for worse outcomes compared to patients with high transvalvular gradients. Surgery or transcatheter aortic valve implantation treatment and high baseline transvalvular gradient are associated with EF improvement.
authors.affiliation: Division of Cardiology, Washington Hospital Center, Washington, District of Columbia, USA.
authors.forename: Itsik
authors.initials: I
authors.lastname: Ben-Dor
authors.forename: Gabriel
authors.initials: G
authors.lastname: Maluenda
authors.forename: Getachew D
authors.initials: GD
authors.lastname: Iyasu
authors.forename: Ana
authors.initials: A
authors.lastname: Laynez-Carnicero
authors.forename: Camille
authors.initials: C
authors.lastname: Hauville
authors.forename: Rebecca
authors.initials: R
authors.lastname: Torguson
authors.forename: Petros
authors.initials: P
authors.lastname: Okubagzi
authors.forename: Zhenyi
authors.initials: Z
authors.lastname: Xue
authors.forename: Steven A
authors.initials: SA
authors.lastname: Goldstein
authors.forename: Joseph
authors.initials: J
authors.lastname: Lindsay
authors.forename: Lowell F
authors.initials: LF
authors.lastname: Satler
authors.forename: Augusto D
authors.initials: AD
authors.lastname: Pichard
authors.forename: Ron
authors.initials: R
authors.lastname: Waksman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006328:Cardiac Catheterization / Q000379:methods; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D016019:Survival Analysis; D016896:Treatment Outcome