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. 2016 Jul 21;37(28):2276-86.
doi: 10.1093/eurheartj/ehv701. Epub 2016 Jan 18.

Aortic valve surgery and survival in patients with moderate or severe aortic stenosis and left ventricular dysfunction

Zainab Samad  1 , Amit N Vora  2 , Allison Dunning  3 , Phillip J Schulte  3 , Linda K Shaw  3 , Fawaz Al-Enezi  4 , Mads Ersboll  5 , Robert W McGarrah 3rd  4 , John P Vavalle  4 , Svati H Shah  6 , Joseph Kisslo  4 , Donald Glower  7 , J Kevin Harrison  4 , Eric J Velazquez  2
Affiliations

Aortic valve surgery and survival in patients with moderate or severe aortic stenosis and left ventricular dysfunction

Zainab Samad et al. Eur Heart J. .

Abstract

Aims: 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.

Methods and results: 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].

Conclusions: 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.

Keywords: Moderate aortic stenosis; aortic valve surgery; left ventricular systolic dysfunction; severe aortic stenosis; survival.

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Figures

Figure 1
Figure 1
Use of aortic valve surgery among entire cohort by aortic stenosis severity is described on the left of the vertical bar and by severity of left ventricular systolic dysfunction on the right. Aortic stenosis severity is defined by mean gradients.
Figure 2
Figure 2
Cumulative incidence of aortic valve surgery by aortic stenosis severity and left ventricular systolic dysfunction.
Figure 3
Figure 3
Survival curves stratified by aortic valve surgery.
Figure 4
Figure 4
Multivariate and propensity adjusted models examining the impact of aortic valve surgery on survival. All P < 0.001; analysis includes patients with mean aortic valve gradients ≥25 mmHg.
Figure A1
Figure A1
Adjusted product limit survival estimates of patients with moderate aortic stenosis and left ventricular systolic dysfunction and no known coronary artery disease stratified by aortic valve surgery. Aortic stenosis is defined by mean gradient criteria.
Figure A2
Figure A2
Adjusted product-limit survival estimates of patients with severe aortic stenosis and left ventricular systolic dysfunction and no known coronary artery disease stratified by aortic valve surgery. Aortic stenosis is defined by mean gradient criteria.
Figure A3
Figure A3
Adjusted product-limit survival estimates of patients with AVA > 1.0 cm2 and left ventricular systolic dysfunction stratified by aortic valve surgery.
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