Aortic Valve Replacement for Low-Flow/Low-Gradient Aortic Stenosis

Lévy, F.; Laurent, Marcel; Monin, Jean Luc; Maillet, J; Pasquet, Agnès; Tourneau, Thierry Le; Petit‐Eisenmann, Hélène; Gori, Mauro; Jobic, Yannick; Bauer, Fabrice; Chauvel, Christophe; Leguerrier, Alain; Tribouilloy, Christophe

doi:10.1016/j.jacc.2007.10.067

Cited by 245 publications

(54 citation statements)

References 22 publications

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“…This phenotype is often misleading for clinicians because establishing the diagnosis can be challenging and the prognosis falsely reassuring given a heart that is not dilated or hypokinetic (to the contrary, the LV often appears hyperdynamic). However, studies have convincingly shown, and our data reaffirm, that paradoxical low‐gradient AS constitutes a particularly high‐risk group with operative risk of 6% to 33% and medically treated survival <50% at 3 years 27, 28, 29, 30. Patients with paradoxical low‐gradient AS are particularly vulnerable to the deleterious effects of patient‐prosthesis mismatch and, accordingly, may be good candidates for TAVR.…”

Section: Discussionsupporting

confidence: 75%

Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram

Tan

Flynn

Chen‐Tournoux

et al. 2015

JAHA

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BackgroundRisk prediction is a critical step in patient selection for aortic valve replacement (AVR), yet existing risk scores incorporate very few echocardiographic parameters. We sought to evaluate the incremental predictive value of a complete echocardiogram to identify high‐risk surgical candidates before AVR.Methods and ResultsA cohort of patients with severe aortic stenosis undergoing surgical AVR with or without coronary bypass was assembled at 2 tertiary centers. Preoperative echocardiograms were reviewed by independent observers to quantify chamber size/function and valve function. Patient databases were queried to extract clinical data. The cohort consisted of 432 patients with a mean age of 73.5 years and 38.7% females. Multivariable logistic regression revealed 3 echocardiographic predictors of in‐hospital mortality or major morbidity: E/e’ ratio reflective of elevated left ventricular (LV) filling pressure; myocardial performance index reflective of right ventricular (RV) dysfunction; and small LV end‐diastolic cavity size. Addition of these echocardiographic parameters to the STS risk score led to an integrated discrimination improvement of 4.1% (P<0.0001). After a median follow‐up of 2 years, Cox regression revealed 5 echocardiographic predictors of all‐cause mortality: small LV end‐diastolic cavity size; LV mass index; mitral regurgitation grade; right atrial area index; and mean aortic gradient <40 mm Hg.ConclusionsEchocardiographic measures of LV diastolic dysfunction and RV performance add incremental value to the STS risk score and should be integrated in prediction when evaluating the risk of AVR. In addition, findings of small hypertrophied LV cavities and/or low mean aortic gradients confer a higher risk of 2‐year mortality.

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Section: Discussionsupporting

confidence: 75%

Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram

Tan

Flynn

Chen‐Tournoux

et al. 2015

JAHA

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“…23 Nonrandomized data suggest that regardless of the origin, patients with LF AS with LG have worse outcomes with and without surgery yet may still benefit from valve replacement compared with MM. 6,[8][9][10][11][12][13][14] In our analysis of patients with severe AS and predominantly not LGs, a low stroke volume was an important independent predictor of midterm all-cause mortality compared with patients with NF. Although current guidelines emphasize the importance of EF in the evaluation of patients with AS for surgery even when asymptomatic, our data suggest that EF may be less important after adjustment for flow.…”

Section: Pathophysiology Of Lfmentioning

confidence: 59%

“…[3][4][5][6][7] These patients have a prognosis similar to or worse than that for patients with classic AS, both with and without surgery. [6][7][8][9][10][11][12][13][14] However, little is known about the prognostic value of LF independently of gradient and EF and its treatment.…”

mentioning

confidence: 99%

Predictors of Mortality and Outcomes of Therapy in Low-Flow Severe Aortic Stenosis

et al. 2013

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Background-The prognosis and treatment of patients with low-flow (LF) severe aortic stenosis are controversial. Methods and Results-The Placement of Aortic Transcatheter Valves (PARTNER) trial randomized patients with severe aortic stenosis to medical management versus transcatheter aortic valve replacement (TAVR; inoperable cohort) and surgical aortic valve replacement versus TAVR (high-risk cohort). Among 971 patients with evaluable echocardiograms (92%), LF (stroke volume index ≤35 mL/m 2 ) was observed in 530 (55%); LF and low ejection fraction (<50%) in 225 (23%); and LF, low ejection fraction, and low mean gradient (<40 mm Hg) in 147 (15%). Two-year mortality was significantly higher in patients with LF compared with those with normal stroke volume index (47% versus 34%; hazard ratio, 1.5; 95% confidence interval, 1.25-1.89; P=0.006). In the inoperable cohort, patients with LF had higher mortality than those with normal flow, but both groups improved with TAVR (46% versus 76% with LF and 38% versus 53% with normal flow; P<0.001). In the high-risk cohort, there was no difference between TAVR and surgical aortic valve replacement. In patients with paradoxical LF and low gradient (preserved ejection fraction), TAVR reduced 1-year mortality from 66% to 35% (hazard ratio, 0.38; P=0.02). LF was an independent predictor of mortality in all patient cohorts (hazard ratio, ≈1.5), whereas ejection fraction and gradient were not. Conclusions-LF

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“…According to recent studies, patients with left ventricular contractile reserve (CR) on DSE (i.e., an increase in stroke volume under dobutamine infusion of Ն20% compared with the baseline value) have a relatively low operative mortality, about 5% to 7% (2,3). Therefore, patients with severe LF/LGAS and CR have an acceptable operative risk, and aortic valve replacement (AVR) improves long-term survival and functional status in most cases (2)(3)(4).…”

Section: Discussionmentioning

confidence: 99%

Outcome After Aortic Valve Replacement for Low-Flow/Low-Gradient Aortic Stenosis Without Contractile Reserve on Dobutamine Stress Echocardiography

Tribouilloy

Lévy

Ruşinaru

et al. 2009

Journal of the American College of Cardiology

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331

229

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Aortic Valve Replacement for Low-Flow/Low-Gradient Aortic Stenosis

Abstract: In view of the very poor prognosis of unoperated patients, the current operative risk, and the long-term outcome after surgery, AVR is the treatment of choice in the majority of cases of LF/LGAS.

Cited by 245 publications

References 22 publications

Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram

Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram

Predictors of Mortality and Outcomes of Therapy in Low-Flow Severe Aortic Stenosis

Outcome After Aortic Valve Replacement for Low-Flow/Low-Gradient Aortic Stenosis Without Contractile Reserve on Dobutamine Stress Echocardiography

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