title: Impact of Ejection Fraction and Aortic Valve Gradient on Outcomes of Transcatheter Aortic Valve Replacement.
abstract: In patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), studies have suggested that reduced left ventricular (LV) ejection fraction (LVEF) and low aortic valve gradient (AVG) are associated with worse long-term outcomes. Because these conditions commonly coexist, the extent to which they are independently associated with outcomes after TAVR is unknown.
  
  
  
  The purpose of this study was to evaluate the impact of LVEF and AVG on clinical outcomes after TAVR and to determine whether the effect of AVG on outcomes is modified by LVEF.
  
  
  
  Using data from 11,292 patients who underwent TAVR as part of the Transcatheter Valve Therapies Registry, we examined rates of 1-year mortality and recurrent heart failure in patients with varying levels of LV dysfunction (LVEF <30% vs. 30% to 50% vs. >50%) and AVG (<40 mm Hg vs. ≥40 mm Hg). Multivariable models were used to estimate the independent effect of AVG and LVEF on outcomes.
  
  
  
  During the first year of follow-up after TAVR, patients with LV dysfunction and low AVG had higher rates of death and recurrent heart failure. After adjustment for other clinical factors, only low AVG was associated with higher mortality (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32; p < 0.001) and higher rates of heart failure (hazard ratio: 1.52; 95% confidence interval: 1.36 to 1.69; p <0.001), whereas the effect of LVEF was no longer significant. There was no evidence of effect modification between AVG and LVEF with respect to either endpoint.
  
  
  
  In this series of real-world patients undergoing TAVR, low AVG, but not LV dysfunction, was associated with higher rates of mortality and recurrent heart failure. Although these findings suggest that AVG should be considered when evaluating the risks and benefits of TAVR for individual patients, neither severe LV dysfunction nor low AVG alone or in combination provide sufficient prognostic discrimination to preclude treatment with TAVR.
authors.affiliation: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri.
authors.forename: Suzanne J
authors.initials: SJ
authors.lastname: Baron
authors.affiliation: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri.
authors.forename: Suzanne V
authors.initials: SV
authors.lastname: Arnold
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, Philadelphia.
authors.forename: Howard C
authors.initials: HC
authors.lastname: Herrmann
authors.affiliation: Mayo Clinic, Rochester, Minnesota.
authors.forename: David R
authors.initials: DR
authors.lastname: Holmes
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, Philadelphia.
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.affiliation: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri.
authors.forename: Keith B
authors.initials: KB
authors.lastname: Allen
authors.affiliation: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri.
authors.forename: Adnan K
authors.initials: AK
authors.lastname: Chhatriwalla
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Sreekaanth
authors.initials: S
authors.lastname: Vemulapali
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Sean
authors.initials: S
authors.lastname: O'Brien
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Dadi
authors.initials: D
authors.lastname: Dai
authors.affiliation: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri. Electronic address: dcohen@saint-lukes.org.
authors.forename: David J
authors.initials: DJ
authors.lastname: Cohen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000401:mortality / Q000503:physiopathology* / Q000601:surgery*; D001783:Blood Flow Velocity / Q000502:physiology*; D001794:Blood Pressure / Q000502:physiology*; D005500:Follow-Up Studies; D006333:Heart Failure / Q000453:epidemiology; D006801:Humans; D008297:Male; D012008:Recurrence; D012042:Registries; D013318:Stroke Volume / Q000502:physiology*; D065467:Transcatheter Aortic Valve Replacement; D014481:United States / Q000453:epidemiology; D018487:Ventricular Dysfunction, Left / Q000453:epidemiology
keywords: AV gradient; LVEF; TAVR; left ventricular dysfunction; stroke; surgical aortic valve replacement