title: Clinical outcomes and revascularization strategies in patients with low-flow, low-gradient severe aortic valve stenosis according to the assigned treatment modality.
abstract: OBJECTIVE
  This study compared clinical outcomes and revascularization strategies among patients presenting with low ejection fraction, low-gradient (LEF-LG) severe aortic stenosis (AS) according to the assigned treatment modality.
  
  
  BACKGROUND
  The optimal treatment modality for patients with LEF-LG severe AS and concomitant coronary artery disease (CAD) requiring revascularization is unknown.
  
  
  METHODS
  Of 1,551 patients, 204 with LEF-LG severe AS (aortic valve area <1.0 cm(2), ejection fraction <50%, and mean gradient <40 mm Hg) were allocated to medical therapy (MT) (n = 44), surgical aortic valve replacement (SAVR) (n = 52), or transcatheter aortic valve replacement (TAVR) (n = 108). CAD complexity was assessed using the SYNTAX score (SS) in 187 of 204 patients (92%). The primary endpoint was mortality at 1 year.
  
  
  RESULTS
  LEF-LG severe AS patients undergoing SAVR were more likely to undergo complete revascularization (17 of 52, 35%) compared with TAVR (8 of 108, 8%) and MT (0 of 44, 0%) patients (p < 0.001). Compared with MT, both SAVR (adjusted hazard ratio [adj HR]: 0.16; 95% confidence interval [CI]: 0.07 to 0.38; p < 0.001) and TAVR (adj HR: 0.30; 95% CI: 0.18 to 0.52; p < 0.001) improved survival at 1 year. In TAVR and SAVR patients, CAD severity was associated with higher rates of cardiovascular death (no CAD: 12.2% vs. low SS [0 to 22], 15.3% vs. high SS [>22], 31.5%; p = 0.037) at 1 year. Compared with no CAD/complete revascularization, TAVR and SAVR patients undergoing incomplete revascularization had significantly higher 1-year cardiovascular death rates (adj HR: 2.80; 95% CI: 1.07 to 7.36; p = 0.037).
  
  
  CONCLUSIONS
  Among LEF-LG severe AS patients, SAVR and TAVR improved survival compared with MT. CAD severity was associated with worse outcomes and incomplete revascularization predicted 1-year cardiovascular mortality among TAVR and SAVR patients.
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland; Department of Cardiology, Stadtspital Triemli, Zürich, Switzerland.
authors.forename: Crochan J
authors.initials: CJ
authors.lastname: O'Sullivan
authors.affiliation: Department of Cardiovascular Surgery, Bern University Hospital, Bern, Switzerland.
authors.forename: Lars
authors.initials: L
authors.lastname: Englberger
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Nicola
authors.initials: N
authors.lastname: Hosek
authors.affiliation: Clinical Trials Unit, Bern University Hospital, Bern, Switzerland; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
authors.forename: Dik
authors.initials: D
authors.lastname: Heg
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Davide
authors.initials: D
authors.lastname: Cao
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Giulio G
authors.initials: GG
authors.lastname: Stefanini
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Stefan
authors.initials: S
authors.lastname: Stortecky
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Steffen
authors.initials: S
authors.lastname: Gloekler
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Ernest
authors.initials: E
authors.lastname: Spitzer
authors.affiliation: Department of Cardiology, Stadtspital Triemli, Zürich, Switzerland.
authors.forename: David
authors.initials: D
authors.lastname: Tüller
authors.affiliation: Department of Cardiovascular Surgery, Bern University Hospital, Bern, Switzerland.
authors.forename: Christoph
authors.initials: C
authors.lastname: Huber
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Thomas
authors.initials: T
authors.lastname: Pilgrim
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Fabien
authors.initials: F
authors.lastname: Praz
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Lutz
authors.initials: L
authors.lastname: Buellesfeld
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Ahmed A
authors.initials: AA
authors.lastname: Khattab
authors.affiliation: Department of Cardiovascular Surgery, Bern University Hospital, Bern, Switzerland.
authors.forename: Thierry
authors.initials: T
authors.lastname: Carrel
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Meier
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland; Clinical Trials Unit, Bern University Hospital, Bern, Switzerland.
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland. Electronic address: Peter.Wenaweser@insel.ch.
authors.forename: Peter
authors.initials: P
authors.lastname: Wenaweser
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology*; D001024:Aortic Valve Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D003326:Coronary Circulation; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006439:Hemodynamics; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D009204:Myocardial Revascularization / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D016016:Proportional Hazards Models; D012042:Registries; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D013557:Switzerland; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left
keywords: aortic stenosis; coronary artery disease; surgical aortic valve replacement; transcatheter aortic valve replacement