Impact of Ejection Fraction on Long-Term Outcome After Elective Aortic Valve Replacement in Octogenarians With Aortic Stenosis

Abstract

Background: Aortic stenosis (AS) is increasingly common in the elderly population. A recent invention of transcatheter aortic valve implantation tends to tilt the risk-benefit balance to favor earlier elective intervention for AS. Hence, decision making for elective intervention in octogenarians gradually becomes important. However, the outcome after elective aortic valve replacement (eAVR) has not been evaluated adequately. This study aimed to identify risk factors after eAVR in octogenarians and investigate their influence on long-term outcome. Methods and Results:One hundred and thirty-seven consecutive Japanese octogenarians with AS who underwent eAVR were studied. The mean follow-up period was 35±22 (range, 0-88) months. Long-term overall survival rates after eAVR were 92.0%, 85.2% and 75.5% at 1, 3 and 5 years, respectively. Cox proportional hazards model identified age [hazard ratio (HR) 1.23; 95% confidence interval (CI) 1.07-1.43; P<0.01)] and ejection fraction (EF) <50% (HR 3.38; 95%CI 1.34-8.52; P<0.01) as the risk factors of mortality. Post-eAVR survival rates in octogenarians with an EF ≥50% and <50% were 97.3% and 70.4% at 1 year, 90.1% and 65.3% at 3 years, and 84.3% and 39.2% at 5 years, respectively (P<0.0001). Conclusions:Octogenarians with preserved LV systolic function before surgery have favorable long-term survival after eAVR. However, an EF <50% influences the mortality in octogenarian patients. Therefore, eAVR should be considered for octogenarians with AS before the progression of LV impairment. Methods Study PopulationA retrospective study was conducted with 137 consecutive Japanese octogenarians who underwent eAVR for AS between July 2004 and October 2010 at the Department of Cardiovascular Surgery of the Sakakibara Heart Institute, Tokyo, Japan. Preoperative demographic and perioperative data were retrieved from our computerized database. The primary end point was survival, which was obtained by reviewing inpatient records and follow-up records at outpatient clinics attended by discharged patients, and telephone interviews for a longer term outcome of 1 year or longer after surgery. This study was approved by the human ethics committee of the Sakakibara Heart Institute. Informed consent regarding participation in any clinical research was obtained from all subjects through the Sakakibara Heart Integrative Profile when patients were admitted to our hospital, and their data was available for this study. EchocardiographyComprehensive 2D and Doppler transthoracic echocardiography was performed at the Sakakibara Heart Institute in all patients within 2 months before and 1 week after AVR. A midterm follow-up echocardiography was performed at random from 3 months to 1 year after hospital discharge. A long-term follow-up echocardiography was performed routinely at 1 year after and beyond.Peak transaortic velocity (Vp) and mean transaortic pressure gradient (MPG) were measured by continuous wave Doppler using a multiwindow approach. The aortic valve area (AVA) and actual effective orifice are...

Prognostic implications in patients with symptomatic aortic stenosis and preserved ejection fraction: Japanese multicenter aortic stenosis, retrospective (JUST-R) registry

“…LV systolic parameters, such as LV end-systolic volume and LVEF, were most preserved in the patients with chest pain compared to those in the other three groups in this study. LV systolic function also closely correlated with the clinical outcome in AS patients irrespective of AV surgery [21][22][23]. These findings appear to support why the AS patients with chest pain had better prognosis in this study.…”

Heart Failure after Aortic Valve Replacement for Aortic Valve Stenosis: Possible Mechanisms

“…Since mortality of unoperated AS is high on short term, postoperative studies with focus on LV parameters have been included, in order to obtain mid and longterm effects of AVR. By comparing series over a long time-span, the effect of improved operative techniques and postoperative care have not been included in this manuscript, although these improvements may interfere with the effect of patient-related factors on the outcome after AVR [14]. Furthermore, papers concerning non-ventricular factors with an effect on postoperative CHF such as conduction defects, atrial fibrillation, coronary artery disease [10] and valveprosthesis-patient-mismatch [15], have not been included.…”

“…The E wave represents the early diastolic peak of trans-mitral flow [22,46] and is determined by the pressure gradient between the LA and the LV. The latter is affected by LVF [14,49]. Early diastolic filling increases in patients with AS [17,18].…”

“…The early diastolic mitral annular motion E', is related to recoil and relaxation of the LV and is independent from preload. It serves as indicator for diastolic dysfunction [14]: E' reduces when LV relaxation is impaired, [48], such as in patients with AS [8,17,22,53]. E' is measured at the septal and the lateral side and corrects for the influence of myocardial relaxation on the trans-mitral flow E. Mitral annular calcification, which can be observed in patients with AS, is a confounding factor for E'.…”

Thallium-201 gated single-photon emission tomography for assessing left ventricular volumes and function in patients with aortic valve stenosis: Comparison with echocardiography as the reference standard

“…Previous studies have shown that left ventricular ejection fraction (EF) is strongly associated with outcome in patients with AS [4], [5], [6], and it is clinically important to assess left ventricular volumes and function. Echocardiography and quantitative gated single photon emission computed tomography (SPECT) [QGS] are commonly used for assessing left ventricular volumes and function, and several studies have shown good correlations between the 2 methods [7], [8], [9].…”