title: Impact of preoperative left ventricular ejection fraction on long-term survival after aortic valve replacement for aortic stenosis.
abstract: BACKGROUND
  The survival of patients who undergo aortic valve replacement (AVR) for severe aortic stenosis with reduced preoperative ejection fractions (EFs) is not well described in the literature.
  
  
  RESULTS
  Patients undergoing AVR for severe aortic stenosis were analyzed using the Northern New England Cardiovascular Disease Study Group surgical registry. Patients were stratified by preoperative EF (≥50%, 40%-49%, and <40%) and concomitant coronary artery bypass grafting. Crude and adjusted survival across strata of EF was estimated for patients up to 8 years beyond their index admission. A total of 5277 patients underwent AVR for severe aortic stenosis between 1992 and 2008. There were 727 (14%) patients with preoperative EF <40%. Preoperative EF had minimal effect on postoperative morbidity. There was no difference in 30-day mortality across EF strata among the isolated AVR cohort. Preserved EF conferred 30-day survival benefit among the AVR+coronary artery bypass grafting population (EF≥50%, 96%; EF<40%, 91%; P=0.003). Patients with preserved EF had significantly improved 6-month and 8-year survival compared with their reduced EF counterparts.
  
  
  CONCLUSIONS
  Survival after AVR or AVR+coronary artery bypass grafting was most favorable among patients with preoperative preserved EF. However, patients with mild to moderately depressed EF experienced a substantial survival benefit compared with the natural history of medically treated patients. Furthermore, minor reductions of EF carried equivalent increased risk to those with more compromised function suggesting patients are best served when an AVR is performed before even minor reductions in myocardial function.
authors.affiliation: Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH 03756, USA. joshua.b.goldberg@hitchcock.org
authors.forename: Joshua B
authors.initials: JB
authors.lastname: Goldberg
authors.forename: Joseph P
authors.initials: JP
authors.lastname: DeSimone
authors.forename: Robert S
authors.initials: RS
authors.lastname: Kramer
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Discipio
authors.forename: Louis
authors.initials: L
authors.lastname: Russo
authors.forename: Lawrence J
authors.initials: LJ
authors.lastname: Dacey
authors.forename: Bruce J
authors.initials: BJ
authors.lastname: Leavitt
authors.forename: Robert E
authors.initials: RE
authors.lastname: Helm
authors.forename: Yvon R
authors.initials: YR
authors.lastname: Baribeau
authors.forename: Gerald
authors.initials: G
authors.lastname: Sardella
authors.forename: Robert A
authors.initials: RA
authors.lastname: Clough
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Surgenor
authors.forename: Meredith J
authors.initials: MJ
authors.lastname: Sorensen
authors.forename: Cathy S
authors.initials: CS
authors.lastname: Ross
authors.forename: Elaine M
authors.initials: EM
authors.lastname: Olmstead
authors.forename: Todd A
authors.initials: TA
authors.lastname: MacKenzie
authors.forename: David J
authors.initials: DJ
authors.lastname: Malenka
authors.forename: Donald S
authors.initials: DS
authors.lastname: Likosky
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery*; D001026:Coronary Artery Bypass; D005260:Female; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009511:New England / Q000453:epidemiology; D057234:Preoperative Period; D011446:Prospective Studies; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume / Q000502:physiology*; D015996:Survival Rate; D016896:Treatment Outcome; D016277:Ventricular Function, Left / Q000502:physiology*