title: Transcatheter aortic valve implantation in low ejection fraction/low transvalvular gradient patients: the rule of 40.
abstract: BACKGROUND
  Several factors have been identified as predictors of events after transcatheter aortic valve implantation (TAVI) but the impact of left ventricular ejection fraction (LVEF) and mean transaortic gradient (MTG) is controversial. This multicenter study aimed to clarify the prognostic role of low LVEF and low MTG after TAVI.
  
  
  METHODS
  From 2007 to 2012, 764 consecutive patients with severe symptomatic aortic valve stenosis underwent TAVI at participating hospitals. Patients were divided according to LVEF and MTG into four groups.
  
  
  RESULTS
  Sixty-four patients had LVEF 40% or less and MTG less than 40 mmHg, 76 had LVEF 40% or less and MTG at least 40 mmHg, 163 had LVEF more than 40% and MTG less than 40 mmHg, 461 had LVEF more than 40% and MTG at least 40 mmHg. Two-year mortality was significantly higher in patients with low LVEF and low MTG, whereas it was similar in patients with low LVEF and high MTG, high LVEF and low MTG, and high LVEF and high MTG (51.3 vs. 22.4 vs. 23.3. vs. 25.5%, respectively; P = 0.001). These results were confirmed by multivariate analysis, as the combination of low LVEF and low MTG (both less than 40) was identified as the stronger mid-term mortality predictor (hazard ratio 2.4, confidence interval 95% 1.4-3.9; P = 0.001).
  
  
  CONCLUSIONS
  At least one parameter between LVEF or MTG over 40 predicts a good prognosis for TAVI patients at mid-term follow-up, whereas those with both left ventricular dysfunction and low mean aortic pressure gradient are at high risk of all-cause death after TAVI.
authors.affiliation: aDivision of Cardiology, Città Della Salute e della Scienza Hospital, Turin, Italy bDepartment of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands cDivision of Cardiology, Istituto Clinico Humanitas dDepartment of Cardiology, Clinical Institute S. Ambrogio, Milan eDepartment of Cardiac, Thoracic and Vascular Sciences, Division of Cardiology, University of Padova, Padova fDivision of Cardiology, Policlinico Sant'Orsola-Malpighi, Bologna gDivision of Cardiac Surgery, Città Della Salute e della Scienza Hospital, University of Turin, Turin, Italy.
authors.forename: Federico
authors.initials: F
authors.lastname: Conrotto
authors.forename: Fabrizio
authors.initials: F
authors.lastname: D'Ascenzo
authors.forename: Pieter
authors.initials: P
authors.lastname: Stella
authors.forename: Marco
authors.initials: M
authors.lastname: Pavani
authors.forename: Marco Luciano
authors.initials: ML
authors.lastname: Rossi
authors.forename: Nedy
authors.initials: N
authors.lastname: Brambilla
authors.forename: Massimo
authors.initials: M
authors.lastname: Napodano
authors.forename: Elisa
authors.initials: E
authors.lastname: Covolo
authors.forename: Francesco
authors.initials: F
authors.lastname: Saia
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Tarantini
authors.forename: Pierfrancesco
authors.initials: P
authors.lastname: Agostoni
authors.forename: Antonio
authors.initials: A
authors.lastname: Marzocchi
authors.forename: Patrizia
authors.initials: P
authors.lastname: Presbitero
authors.forename: Francesco
authors.initials: F
authors.lastname: Bedogni
authors.forename: Stefano
authors.initials: S
authors.lastname: Salizzoni
authors.forename: Maurizio
authors.initials: M
authors.lastname: D'Amico
authors.forename: Claudio
authors.initials: C
authors.lastname: Moretti
authors.forename: Mauro
authors.initials: M
authors.lastname: Rinaldi
authors.forename: Fiorenzo
authors.initials: F
authors.lastname: Gaita
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery; D001024:Aortic Valve Stenosis / Q000401:mortality* / Q000601:surgery*; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D008297:Male; D015999:Multivariate Analysis; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012720:Severity of Illness Index; D013318:Stroke Volume; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects*; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000503:physiopathology*; D016277:Ventricular Function, Left