title: Aortic valve surgery and survival in patients with moderate or severe aortic stenosis and left ventricular dysfunction.
abstract: We aimed to determine the frequency of aortic valve surgery (AVR) with or without coronary artery bypass grafting (CABG), among patients with moderate/severe aortic stenosis (AS) and left ventricular systolic dysfunction (LVSD), and its relationship with survival.
  
  
  
  The Duke Echocardiographic Database (N = 132 804) was queried for patients with mean gradient ≥25 mmHg and/or peak velocity ≥3 m/s and LVSD (left ventricular ejection fraction ≤50%) from 1 January 1995-28 February 2014. For analyses purposes, AS was defined both by mean gradient and calculated aortic valve area (AVA) criteria. Time-dependent indicators of AVR in multivariable Cox models were used to assess the relationship of AVR and all-cause mortality. A total of 1634 patients had moderate (N = 1090, 67%) or severe (N = 544, 33%) AS by mean gradient criteria. Overall, 287 (26%) patients with moderate AS and 263 (48%) patients with severe AS underwent AVR within 5 years of the qualifying echo. There were 863 (53%) deaths observed up to 5 years following index echo. After multivariable adjustment in an inverse probability weighted regression model, AVR was associated with higher 5-year survival amongst patients with moderate AS and severe AS whether classified by AVA or mean gradient criteria. Over all, AVR ± CABG compared with medical therapy was associated with significantly lower mortality [hazard ratio, HR = 0.49 (0.38, 0.62), P < 0.0001]. Compared with CABG alone, CABG + AVR was associated with better survival [HR = 0.18 (0.12, 0.27), P < 0.0001].
  
  
  
  In patients with moderate/severe AS and LVSD, mortality is substantial and amongst those selected for surgery, AVR with or without CABG is associated with higher survival. Research is required to understand factors contributing to current practice patterns and the possible utility of transcatheter approaches in this high-risk cohort.
authors.affiliation: Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA zainab.samad@dm.duke.edu.
authors.forename: Zainab
authors.initials: Z
authors.lastname: Samad
authors.affiliation: Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA Duke Clinical Research Institute, Durham, NC, USA.
authors.forename: Amit N
authors.initials: AN
authors.lastname: Vora
authors.affiliation: Duke Clinical Research Institute, Durham, NC, USA.
authors.forename: Allison
authors.initials: A
authors.lastname: Dunning
authors.affiliation: Duke Clinical Research Institute, Durham, NC, USA.
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Schulte
authors.affiliation: Duke Clinical Research Institute, Durham, NC, USA.
authors.forename: Linda K
authors.initials: LK
authors.lastname: Shaw
authors.affiliation: Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA.
authors.forename: Fawaz
authors.initials: F
authors.lastname: Al-Enezi
authors.affiliation: Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.
authors.forename: Mads
authors.initials: M
authors.lastname: Ersboll
authors.affiliation: Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA.
authors.forename: Robert W
authors.initials: RW
authors.lastname: McGarrah
authors.affiliation: Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA.
authors.forename: John P
authors.initials: JP
authors.lastname: Vavalle
authors.affiliation: Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA Duke Clinical Research Institute, Durham, NC, USA Duke Molecular Physiology Institute, Durham, NC, USA.
authors.forename: Svati H
authors.initials: SH
authors.lastname: Shah
authors.affiliation: Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Kisslo
authors.affiliation: Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA Department of Surgery, Duke University, Durham, NC, USA.
authors.forename: Donald
authors.initials: D
authors.lastname: Glower
authors.affiliation: Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA.
authors.forename: J Kevin
authors.initials: JK
authors.lastname: Harrison
authors.affiliation: Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA Duke Clinical Research Institute, Durham, NC, USA.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
mesh_terms: D001021:Aortic Valve; D001024:Aortic Valve Stenosis; D001026:Coronary Artery Bypass; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left
keywords: Moderate aortic stenosis; aortic valve surgery; left ventricular systolic dysfunction; severe aortic stenosis; survival