Aortic valve replacement in severe aortic stenosis with left ventricular dysfunction: determinants of cardiac mortality and ventricular function recovery

Tarantini, Giuseppe; Buja, Paolo; Scognamiglio, R; Razzolini, Renato; Gerosa, Gino; Isabella, Giambattista; Ramondo, Angelo; Iliceto, Sabino

doi:10.1016/s1010-7940(03)00575-x

Cited by 94 publications

(55 citation statements)

References 19 publications

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“…Table 4 presents the in-hospital mortality rates of high-risk patients undergoing SAVR. The 30-day mortality rate of 9.6% observed in TAVI patients in our study is encouraging in light of the reported inhospital mortality rates of selected octogenarians (4.6% to 13.5%) [4][5][6][7][8][9][10][11] , patients with left ventricular dysfunction (6% to 33%) 12,13,[26][27][28][29][30][31] and patients with high logistic EuroSCORES (7.8%) undergoing surgical aortic valve replacement 32 . While surgical heart valve replacement remains the standard of care, several studies have demonstrated that 30% to 60% of patients with symptomatic severe aortic valve stenosis are denied or not referred for surgery [33][34][35][36] .…”

Section: Discussionsupporting

confidence: 64%

A comparison of patient characteristics and 30-day mortality outcomes after transcatheter aortic valve implantation and surgical aortic valve replacement for the treatment of aortic stenosis: a two-centre study

Piazza¹,

Gameren²,

Jüni³

et al. 2009

EuroIntervention

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Aims: It is unclear whether transcatheter aortic valve implantation (TAVI) addresses an unmet clinical need for those currently rejected for surgical aortic valve replacement (SAVR) and whether there is a subgroup of high-risk patients benefiting more from TAVI compared to SAVR. In this two-centre, prospective cohort study, we compared baseline characteristics and 30-day mortality between TAVI and SAVR in consecutive patients undergoing invasive treatment for aortic stenosis. Methods and results: We pre-specified different adjustment methods to examine the effect of TAVI as compared with SAVR on overall 30-day mortality: crude univariable logistic regression analysis, multivariable analysis adjusted for baseline characteristics, analysis adjusted for propensity scores, propensity score matched analysis, and weighted analysis using the inverse probability of treatment (IPT) as weights. A total of 1,122 patients were included in the study: 114 undergoing TAVI and 1,008 patients undergoing SAVR. The crude mortality rate was greater in the TAVI group (9.6% vs. 2.3%) yielding an odds ratio [OR] of 4.57 (95%-CI 2.17-9.65). Compared to patients undergoing SAVR, patients with TAVI were older, more likely to be in NYHA class III and IV, and had a considerably higher logistic EuroSCORE and more comorbid conditions. Adjusted OR depended on the method used to control for confounding and ranged from 0.60 (0.11-3.36) to 7.57 (0.91-63.0). We examined the distribution of propensity scores and found scores to overlap sufficiently only in a narrow range. In patients with sufficient overlap of propensity scores, adjusted OR ranged from 0.35 (0.04-2.72) to 3.17 (0.31 to 31.9). In patients with insufficient overlap, we consistently found increased odds of death associated with TAVI compared with SAVR irrespective of the method used to control confounding, with adjusted OR ranging from 5. 88 (0.67-51.8) to 25.7 (0.88-750). Approximately one third of patients undergoing TAVI were found to be potentially eligible for a randomised comparison of TAVI versus SAVR. Conclusions: Both measured and unmeasured confounding limit the conclusions that can be drawn from observational comparisons of TAVI versus SAVR. Our study indicates that TAVI could be associated with either substantial benefits or harms. Randomised comparisons of TAVI versus SAVR are warranted.

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Section: Discussionsupporting

confidence: 64%

A comparison of patient characteristics and 30-day mortality outcomes after transcatheter aortic valve implantation and surgical aortic valve replacement for the treatment of aortic stenosis: a two-centre study

Piazza¹,

Gameren²,

Jüni³

et al. 2009

EuroIntervention

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“…All of these patients demonstrated contractile reserve with dobutamine echocardiography, as patients without adequate contractile reserve were not enrolled in these 2 trials. Contractile reserve was defined as an augmented mean gradient of >40 mm Hg with escalating doses of dobutamine (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) μg/kg per minute). Of note, simultaneous augmented LVEF was not considered a requirement for inclusion in the trials.…”

Section: Recovery Of Lvef: Time and Predictorsmentioning

confidence: 99%

“…[7][8][9] The response of patients with LV dysfunction to TAVR has become increasingly important: a recent UK TAVR registry demonstrates significant growth in TAVR utilization among patients with depressed LV systolic function, with ≈10% of contemporary TAVR patients having a baseline ejection fraction (EF) of <30%. 2 Recovery of LVEF and associated improvements in clinical outcomes has been demonstrated after both SAVR and Sapien TAVR, 1,[10][11][12] thus making TAVR a reasonable option in this high-risk group. 13,14 A self-expanding aortic valve bioprosthesis may be an attractive treatment option in cases of LV compromise because it does not necessarily require balloon aortic valvuloplasty or pacemaker-induced hemodynamic instability.…”

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confidence: 99%

Early Recovery of Left Ventricular Systolic Function After CoreValve Transcatheter Aortic Valve Replacement

Dauerman

Reardon

Popma

et al. 2016

Circ: Cardiovascular Interventions

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Background-Approximately one third of patients with symptomatic aortic stenosis have reduced left ventricular ejection fraction (LVEF) before transcatheter aortic valve replacement. The incidence, predictors, and significance of early LVEF recovery after CoreValve transcatheter aortic valve replacement have not been described. Methods and Results-We studied 156 patients from the CoreValve Extreme and High-Risk trials with LVEF ≤40% at baseline who had 30-day LVEF data. All patients underwent core laboratory echocardiographic assessment of LVEF at baseline, post procedure, discharge, 30 days, 6 months, and 1 year. Early LVEF recovery was defined as an absolute increase of ≥10% in EF at 30 days. One-year outcomes were compared between patients with and without early recovery. Multivariable analysis was performed to determine independent predictors of early recovery. Early LVEF recovery occurred in 62% of patients, generally before discharge. By 30 days LVEF increased >17% compared with baseline in the early recovery group with minimal increase in the no-early recovery group (48.9±8.8% versus 31.5±6.9%; P<0.001).One-year all-cause mortality was numerically (but not statistically) higher in the no-early recovery group (24% versus 12%; P=0.07). Absence of previous myocardial infarction (odds ratio, 0.44; 95% confidence interval, 0.19-1.03) and baseline mean gradient ≥40 mm Hg (odds ratio, 4.59; 95% confidence interval, 1.76-11.96) were identified as predictors of early LVEF recovery. Conclusions-Nearly two thirds of patients with reduced LVEF will have a marked early improvement after transcatheter aortic valve replacement. Early LVEF recovery is associated with improved clinical outcomes and is most likely among patients with higher baseline aortic valve gradients and no previous myocardial infarction. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01240902.(Circ Cardiovasc Interv. 2016;9:e003425.

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“…[1][2][3][4][5] Although patients with LV dysfunction face increased early risk, SAVR for severe AS is associated with a large survival advantage and improvements in LVEF and clinical symptoms when compared with conservative management, regardless of baseline LV function. 2,[6][7][8] However, despite these benefits, the operative risk attributable to LV dysfunction, in combination with advanced age and other comorbid conditions, may preclude surgical intervention. 8 …”

mentioning

confidence: 99%

Outcomes of Transcatheter and Surgical Aortic Valve Replacement in High-Risk Patients With Aortic Stenosis and Left Ventricular Dysfunction

Elmariah

Palacios

McAndrew

et al. 2013

Circ: Cardiovascular Interventions

144

101

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Aortic valve replacement in severe aortic stenosis with left ventricular dysfunction: determinants of cardiac mortality and ventricular function recovery

Abstract: Despite LV dysfunction, aortic valve replacement appears to change drastically the natural history of severe aortic stenosis. Preoperative LV levels predict different postoperative survival rate and LVEF recovery.

Cited by 94 publications

References 19 publications

A comparison of patient characteristics and 30-day mortality outcomes after transcatheter aortic valve implantation and surgical aortic valve replacement for the treatment of aortic stenosis: a two-centre study

A comparison of patient characteristics and 30-day mortality outcomes after transcatheter aortic valve implantation and surgical aortic valve replacement for the treatment of aortic stenosis: a two-centre study

Early Recovery of Left Ventricular Systolic Function After CoreValve Transcatheter Aortic Valve Replacement

Outcomes of Transcatheter and Surgical Aortic Valve Replacement in High-Risk Patients With Aortic Stenosis and Left Ventricular Dysfunction

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