Impact of LV Systolic Function on Outcomes for Severe AS
Impact of LV Systolic Function on Outcomes for Severe AS
Background This study aimed to evaluate the impact of baseline left ventricular (LV) systolic function on clinical and echocardiographic outcomes following transcatheter aortic valve implantation (TAVI). Survival of patients undergoing TAVI was also compared with that of a population undergoing surgical aortic valve replacement.
Methods One hundred forty-seven consecutive patients (mean age = 80 ± 7 years) undergoing TAVI in 2 centers were included. Mean follow-up period was 9.1 ± 5.1 months.
Results At baseline, 34% of patients had impaired LV ejection fraction (LVEF) (<50%) and 66% had normal LVEF (≥50%). Procedural success was similar in these 2 groups (94% vs 97%, P = .41). All patients achieved improvement in transvalvular hemodynamics. At follow-up, patients with a baseline LVEF <50% showed marked LV reverse remodeling, with improvement of LVEF (from 37% ± 8% to 51% ± 11%). Early and late mortality rates were not different between the 2 groups, despite a higher rate of combined major adverse cardiovascular events (MACEs) in patients with a baseline LVEF <50%. The predictors of cumulative MACEs were baseline LVEF (HR = 0.97, 95% CI = 0.94–0.99) and preoperative frailty (HR = 4.20, 95% CI = 2.00–8.84). In addition, long-term survival of patients with impaired or normal LVEF was comparable with that of a matched population who underwent surgical aortic valve replacement.
Conclusions TAVI resulted in significant improvement in LV function and survival benefit in high-risk patients with severe aortic stenosis, regardless of baseline LVEF. Patients with a baseline LVEF <50% were at higher risk of combined MACEs.
Symptomatic severe aortic stenosis (AS) is associated with high mortality if left untreated, and surgical aortic valve replacement (SAVR) is currently the recommended therapeutic approach. When severe AS is associated with left ventricular (LV) dysfunction, due to either afterload mismatch or primary myocardial dysfunction, SAVR still results in significant improvement of LV function and survival. However, patients with depressed LV ejection fraction (EF) undergoing SAVR are associated with higher perioperative and mid-term mortality as compared with those with normal LV systolic function. Furthermore, the combination of LV dysfunction with advanced age and significant comorbidities could result in high predicted operative risk that may outweigh the benefits of SAVR and preclude the surgical intervention.
Over the last few years, transcatheter aortic valve implantation (TAVI) has been proposed as a feasible and effective therapeutic alternative in patients with symptomatic severe AS and high operative risk. In fact, studies have shown excellent and sustained transvalvular hemodynamics post-TAVI, together with a significant improvement in symptoms and quality of life. In addition, good survival rates have been reported post-TAVI, ranging from 74% to 78% at the 1-year follow-up. However, no studies have examined the impact of baseline LV systolic function on the outcomes of patients undergoing TAVI. Therefore, the aims of this study were:
Abstract and Introduction
Abstract
Background This study aimed to evaluate the impact of baseline left ventricular (LV) systolic function on clinical and echocardiographic outcomes following transcatheter aortic valve implantation (TAVI). Survival of patients undergoing TAVI was also compared with that of a population undergoing surgical aortic valve replacement.
Methods One hundred forty-seven consecutive patients (mean age = 80 ± 7 years) undergoing TAVI in 2 centers were included. Mean follow-up period was 9.1 ± 5.1 months.
Results At baseline, 34% of patients had impaired LV ejection fraction (LVEF) (<50%) and 66% had normal LVEF (≥50%). Procedural success was similar in these 2 groups (94% vs 97%, P = .41). All patients achieved improvement in transvalvular hemodynamics. At follow-up, patients with a baseline LVEF <50% showed marked LV reverse remodeling, with improvement of LVEF (from 37% ± 8% to 51% ± 11%). Early and late mortality rates were not different between the 2 groups, despite a higher rate of combined major adverse cardiovascular events (MACEs) in patients with a baseline LVEF <50%. The predictors of cumulative MACEs were baseline LVEF (HR = 0.97, 95% CI = 0.94–0.99) and preoperative frailty (HR = 4.20, 95% CI = 2.00–8.84). In addition, long-term survival of patients with impaired or normal LVEF was comparable with that of a matched population who underwent surgical aortic valve replacement.
Conclusions TAVI resulted in significant improvement in LV function and survival benefit in high-risk patients with severe aortic stenosis, regardless of baseline LVEF. Patients with a baseline LVEF <50% were at higher risk of combined MACEs.
Introduction
Symptomatic severe aortic stenosis (AS) is associated with high mortality if left untreated, and surgical aortic valve replacement (SAVR) is currently the recommended therapeutic approach. When severe AS is associated with left ventricular (LV) dysfunction, due to either afterload mismatch or primary myocardial dysfunction, SAVR still results in significant improvement of LV function and survival. However, patients with depressed LV ejection fraction (EF) undergoing SAVR are associated with higher perioperative and mid-term mortality as compared with those with normal LV systolic function. Furthermore, the combination of LV dysfunction with advanced age and significant comorbidities could result in high predicted operative risk that may outweigh the benefits of SAVR and preclude the surgical intervention.
Over the last few years, transcatheter aortic valve implantation (TAVI) has been proposed as a feasible and effective therapeutic alternative in patients with symptomatic severe AS and high operative risk. In fact, studies have shown excellent and sustained transvalvular hemodynamics post-TAVI, together with a significant improvement in symptoms and quality of life. In addition, good survival rates have been reported post-TAVI, ranging from 74% to 78% at the 1-year follow-up. However, no studies have examined the impact of baseline LV systolic function on the outcomes of patients undergoing TAVI. Therefore, the aims of this study were:
to compare early and long-term clinical outcomes post-TAVI in patients with normal versus impaired LV systolic function;
to evaluate early and long-term changes in LV volumes and function post-TAVI in these 2 groups of patients; and
to compare the survival of patients undergoing TAVI with that of a group undergoing SAVR matched for age, gender, aortic valve area, and LVEF.
