Asymptomatic left ventricular systolic dysfunction in patients with severe aortic stenosis: characteristics and outcomes

Abstract

Objectives: This study sought to determine the prevalence, characteristics, and outcomes of asymptomatic left ventricular (LV) systolic dysfunction in patients with severe aortic stenosis (AS).

Background: Management of asymptomatic patients with severe AS remains controversial. In these patients, LV systolic dysfunction, defined in the guidelines as ejection fraction <50%, is a Class I(C) indication for aortic valve replacement (AVR), but its prevalence is unknown.

Methods: A retrospective study of adults ≥40 years of age with severe valvular AS (peak velocity ≥4 m/s, mean gradient >40 mm Hg, aortic valve area [AVA] <1 cm(2), or AVA index <0.6 cm(2)/m(2)) from 1984 to 2010 was undertaken. Patients with prior cardiac surgery, severe coronary artery disease, or greater than moderate aortic regurgitation were excluded.

Results: Of 9,940 patients with severe AS, 43 (0.4%) patients had asymptomatic LV dysfunction. Age was 73 ± 14 years and 70% were male. Hypertension (78%) and LV hypertrophy (LV mass index 143 ± 36 g/m(2)) were characteristic. Fifty-three percent of these patients developed symptoms at 21 ± 19 months after diagnosis. During 7.5 ± 6.7-year follow-up, 5-year mortality was 48%. After multivariable adjustment, there was no survival advantage with AVR in asymptomatic, severe AS with LV dysfunction (p = 0.51).

Conclusions: In severe AS, the prevalence of asymptomatic LV systolic dysfunction is 0.4%. Despite an asymptomatic clinical status, patients with severe AS and LV ejection fraction <50% have a poor prognosis, with or without AVR.

Figure 1. Asymptomatic Adults with Severe AS and LVEF < 50% (n = 43)

During follow-up of 7.5 ± 6.7 years, 7 patients underwent early AVR and 2 of 43 patients died before scheduled follow-up. Of the remaining 34 patients, 18 developed symptoms, 12 remained asymptomatic and 4 had indeterminate symptom and surgical status.

Figure 2. Unadjusted Survival in Asymptomatic Adults with Severe AS and LVEF < 50%

During a median of 5.6 years follow-up, 33 of 42 patients died. After adjustment for age, gender, and time period (1984–1995 versus 1996–2010) of diagnosis, there was no survival benefit with AVR (p = 0.51).