title: Effect of left ventricular ejection fraction on postoperative outcome in patients with severe aortic stenosis undergoing aortic valve replacement.
abstract: BACKGROUND
  In asymptomatic patients with severe aortic stenosis, guidelines recommend left ventricular ejection fraction (LVEF) of <50% as the threshold for referral for aortic valve replacement. We investigated the importance of LVEF on long-term outcome after aortic valve replacement in symptomatic and asymptomatic patients with severe aortic stenosis.
  
  
  RESULTS
  We retrospectively identified 2017 patients with severe aortic stenosis (aortic valve area<1 cm(2), mean gradient≥40 mm Hg, or indexed aortic valve area<0.6 cm(2)/m(2)) who underwent surgical aortic valve replacement from January 1995 to June 2009. 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%]). During follow-up of 5.3±4.4 years, 1056 (52%) patients died. A decrease in mortality was observed with increasing LVEF, P<0.0001; 5-year mortality estimates (95% confidence interval) were 0.41 (0.35-0.47), LVEF<50%; 0.35 (0.29-0.41), LVEF 50% to 59%; 0.26 (0.23-0.29), LVEF 60% to 69%; and 0.22 (0.18-0.26), LVEF≥70%. Compared with patients with LVEF≥60%, patients with LVEF 50% to 59% had increased mortality (hazard ratio [HR], 1.58; P<0.001), with similar risk increase in both symptomatic (HR, 1.56; P<0.001) and asymptomatic patients (HR, 1.58; P=0.006). Correcting for risk factors, LV mass index, aortic valve area, and stroke volume index, LVEF was independently predictive of mortality (HR, 0.88 per 10%; P<0.001). When this analysis was repeated in the subset of 1333 patients without history of coronary artery disease, LVEF remained associated with mortality (HR, 0.90 per 10%; P=0.009).
  
  
  CONCLUSIONS
  LVEF is a powerful predictor of outcome in patients with severe aortic stenosis undergoing aortic valve replacement, independent of the presence of valve-related symptoms.
authors: From the Division of Cardiovascular Diseases (J.S.D., M.F.E., H.I.M., P.A.P.), Division of Biostatistics (C.G.S.), and Division of Cardiovascular Surgery (R.M.S., H.V.S.), Mayo Clinic, Rochester, MN.
authors: Jordi S
authors: JS
authors: Dahl
authors: From the Division of Cardiovascular Diseases (J.S.D., M.F.E., H.I.M., P.A.P.), Division of Biostatistics (C.G.S.), and Division of Cardiovascular Surgery (R.M.S., H.V.S.), Mayo Clinic, Rochester, MN.
authors: Mackram F
authors: MF
authors: Eleid
authors: From the Division of Cardiovascular Diseases (J.S.D., M.F.E., H.I.M., P.A.P.), Division of Biostatistics (C.G.S.), and Division of Cardiovascular Surgery (R.M.S., H.V.S.), Mayo Clinic, Rochester, MN.
authors: Hector I
authors: HI
authors: Michelena
authors: From the Division of Cardiovascular Diseases (J.S.D., M.F.E., H.I.M., P.A.P.), Division of Biostatistics (C.G.S.), and Division of Cardiovascular Surgery (R.M.S., H.V.S.), Mayo Clinic, Rochester, MN.
authors: Christopher G
authors: CG
authors: Scott
authors: From the Division of Cardiovascular Diseases (J.S.D., M.F.E., H.I.M., P.A.P.), Division of Biostatistics (C.G.S.), and Division of Cardiovascular Surgery (R.M.S., H.V.S.), Mayo Clinic, Rochester, MN.
authors: Rakesh M
authors: RM
authors: Suri
authors: From the Division of Cardiovascular Diseases (J.S.D., M.F.E., H.I.M., P.A.P.), Division of Biostatistics (C.G.S.), and Division of Cardiovascular Surgery (R.M.S., H.V.S.), Mayo Clinic, Rochester, MN.
authors: Hartzell V
authors: HV
authors: Schaff
authors: From the Division of Cardiovascular Diseases (J.S.D., M.F.E., H.I.M., P.A.P.), Division of Biostatistics (C.G.S.), and Division of Cardiovascular Surgery (R.M.S., H.V.S.), Mayo Clinic, Rochester, MN. pellikka.patricia@mayo.edu.
authors: Patricia A
authors: PA
authors: Pellikka
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality* / Q000503:physiopathology* / Q000601:surgery; D058070:Asymptomatic Diseases; D005260:Female; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D011379:Prognosis; D012189:Retrospective Studies; D013318:Stroke Volume; D016019:Survival Analysis; D016896:Treatment Outcome; D014463:Ultrasonography; D016277:Ventricular Function, Left / Q000502:physiology*; D020257:Ventricular Remodeling
keywords: aortic valve; aortic valve stenosis; cardiac surgical procedures; echocardiography; ventricular remodeling