Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Jan;9(1):e001912.
doi: 10.1136/openhrt-2021-001912.

Risk prediction in patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction undergoing TAVI

Sebastian Ludwig  1   2 , Alina Goßling  3 , Moritz Seiffert  3   2 , Dirk Westermann  3   2 , Jan-Malte Sinning  4 , Atsushi Sugiura  4 , Matti Adam  5 , Victor Mauri  5 , Derk Frank  6 , Hatim Seoudy  6 , Tanja Rudolph  7 , Max Potratz  7 , Lenard Conradi  2   8 , Niklas Schofer  3   2
Affiliations

Risk prediction in patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction undergoing TAVI

Sebastian Ludwig et al. Open Heart. 2022 Jan.

Abstract

Objective: Patients with low-flow, low-gradient aortic stenosis (LFLG AS) and reduced left ventricular ejection fraction (LVEF) are known to suffer from poor prognosis after transcatheter aortic valve implantation (TAVI). This study aimed to develop a simple score system for risk prediction in this vulnerable subset of patients.

Methods: All patients with LFLG AS with reduced EF and sufficient CT data for aortic valve calcification (AVC) quantification, who underwent TAVI at five German centres, were retrospectively included. The Risk prEdiction in patients with Low Ejection Fraction low gradient aortic stenosis undergoing TAVI (RELiEF TAVI) score was developed based on multivariable Cox regression for all-cause mortality.

Results: Among all included patients (n=718), RELiEF TAVI score variables were defined as independent predictors of mortality: male sex (HR 1.34 (1.06, 1.68), p=0.013), underweight (HR 3.10 (1.50, 6.40), p=0.0022), chronic obstructive pulmonary disease (HR 1.55 (1.21, 1.99), p=0.001), pulmonary hypertension (HR 1.51 (1.17, 1.94), p=0.0015), atrial fibrillation (HR 1.28 (1.03, 1.60), p=0.028), stroke volume index (HR 0.96 (0.95, 0.98), p<0.001), non-transfemoral access (HR 1.36 (1.05, 1.76), p=0.021) and low AVC density (HR 1.44 (1.15, 1.79), p=0.0012). A score system was developed ranging from 0 to 12 points (risk of 1-year mortality: 13%-99%). Kaplan-Meier analysis for low (0-1 points), moderate (2-4 points) and high RELiEF TAVI score (>4 points) demonstrated rates of 18.0%, 29.0% and 46.1% (p<0.001) for all-cause mortality and 23.8%, 35.9% and 53.4% (p<0.001) for the combined endpoint of all-cause mortality or heart failure rehospitalisation after 1 year, respectively.

Conclusions: The RELiEF TAVI score is based on simple clinical, echocardiographic and CT parameters and might serve as a helpful tool for risk prediction in patients with LFLG AS and reduced LVEF scheduled for TAVI.

Keywords: aortic valve stenosis; echocardiography; transcatheter aortic valve replacement.

PubMed Disclaimer

Conflict of interest statement

Competing interests: SL reports non-financial support from Edwards Lifesciences. MS reports non-financial support from Abbott Vascular, Biotronik, Boehringer Ingelheim, Boston Scientific, Edwards Lifesciences, Nicolai Medizintechnik, OrbusNeich Medical, personal fees from Abiomed, Amgen, AstraZeneca, Bayer Healthcare, Bristol-Myers Squibb, Boston Scientific, Medtronic, Philips and Shockwave Medical, grants from Philips. DW reports personal fees from AstraZeneca, Bayer, Berlin-Chemie and Novartis. J-MS is proctor for Medtronic and Boston Scientific, received research grants and speaker honoraria from Edwards Lifesciences, Medtronic and Boston Scientific. DF is consultant for Edwards Lifesciences and Medtronic and received research funding from Edwards Lifesciences. TR received speaker honoraria from Boston Scientific, Edwards, Medtronic, Abbott. LC is proctor and consultant for Edwards Lifesciences and Boston Scientific and consultant for Medtronic and Abbott Vascular. NS reports personal fees from Boston Scientific and non-financial support from Abbott and Edwards Lifesciences.

Figures

Figure 1
Figure 1
Forest plot for all independent predictors of outcome. HRs for all-cause mortality after multivariable adjustment. AVC, aortic valve calcification; BMI, body mass index; COPD, chronic obstructive pulmonary disease; sPAP, systolic pulmonary artery pressure.
Figure 2
Figure 2
The RELiEF TAVI score. Variables, score point assignment and prediction of 1-year all-cause mortality risk. AVC, aortic valve calcification; BMI, body mass index; COPD, chronic obstructive pulmonary disease; RELiEF TAVI, Risk prEdiction in patients with Low Ejection Fraction low gradient aortic stenosis undergoing TAVI; sPAP, systolic pulmonary artery pressure; SVI, stroke volume index; TAVI, transcatheter aortic valve implantation.
Figure 3
Figure 3
Observed mortality and predicted 1-year all-cause mortality by the RELiEF TAVI score. RELiEF TAVI, Risk prEdiction in patients with Low Ejection Fraction low gradient aortic stenosis undergoing TAVI; TAVI, transcatheter aortic valve implantation.
Figure 4
Figure 4
Kaplan-Meier analysis for different study endpoints according to low (0–1 points), moderate (2–4 points) and high RELiEF TAVI score (>4 points). (A) 1-year all-cause mortality, (B) 1-year cardiovascular mortality, (C) 1-year all-cause mortality or HF hospitalisation. HF, heart failure; RELiEF TAVI, Risk prEdiction in patients with Low Ejection Fraction low gradient aortic stenosis undergoing TAVI; TAVI, transcatheter aortic valve implantation.
See this image and copyright information in PMC

References

    1. Reinöhl J, Kaier K, Reinecke H, et al. Effect of availability of transcatheter aortic-valve replacement on clinical practice. N Engl J Med 2015;373:2438–47. 10.1056/NEJMoa1500893 - DOI - PubMed
    1. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2021:ehab395. 10.1093/eurheartj/ehab395 - DOI - PubMed
    1. Ribeiro HB, Lerakis S, Gilard M, et al. Transcatheter Aortic Valve Replacement in Patients With Low-Flow, Low-Gradient Aortic Stenosis: The TOPAS-TAVI Registry. J Am Coll Cardiol 2018;71:1297–308. 10.1016/j.jacc.2018.01.054 - DOI - PubMed
    1. Herrmann HC, Pibarot P, Hueter I, et al. Predictors of mortality and outcomes of therapy in low-flow severe aortic stenosis: a placement of aortic transcatheter valves (partner) trial analysis. Circulation 2013;127:2316–26. 10.1161/CIRCULATIONAHA.112.001290 - DOI - PubMed
    1. Lauten A, Figulla HR, Möllmann H, et al. TAVI for low-flow, low-gradient severe aortic stenosis with preserved or reduced ejection fraction: a subgroup analysis from the German aortic valve registry (GARY). EuroIntervention 2014;10:850–9. 10.4244/EIJV10I7A145 - DOI - PubMed