Influence of Preoperative Left Ventricular Contractile Reserve on Postoperative Ejection Fraction in Low-Gradient Aortic Stenosis

Abstract

Background-Dobutamine stress hemodynamics (DSH) has the potential to stratify operative risk in low-gradient aortic stenosis (AS), but little is known about the relation between left ventricle contractile reserve and postoperative left ventricular ejection fraction (LVEF). We sought to assess the value of DSH to predict postoperative improvement in LVEF. Methods and Results-Sixty-six consecutive patients with symptomatic severe AS (aortic valve area Յ1 cm 2 ), LVEF Յ40%, and mean pressure gradient Յ40 mm Hg prospectively enrolled in the French multicenter study on low-gradient AS and who survived to aortic valvular replacement (AVR) were included. Preoperative contractile reserve was present in 46 patients (group I; 70%) and absent in 20 patients (group II; 30%). In the overall sample, 58% of patients improved by 2 New York Heart Association (NYHA) classes after AVR. Mean LVEF improved from 29Ϯ6% to 47Ϯ11% (PϽ0.0001). LVEF improved by Ն10 EF units in 38 patients (83%) in group I and in 13 patients (65%) in group II. Mean LVEF improvement was similar in the 2 groups (19Ϯ10% versus 17Ϯ11%; Pϭ0.54). On multivariable analysis, multivessel coronary artery disease (Pϭ0.05) and baseline mean transaortic pressure gradient (Pϭ0.01) were related to LVEF improvement, whereas contractile reserve was not. Conclusions-LVEF increases in the majority of patients with low-gradient AS who survive after AVR. Although the absence of contractile reserve on DSH is related to high operative mortality, it does not predict the absence of LVEF recovery in patients surviving to AVR. These data further support the concept that surgery should not be contraindicated on the basis of absence of contractile reserve alone.

Tricuspid Regurgitation Is Associated With Increased Risk of Mortality in Patients With Low-Flow Low-Gradient Aortic Stenosis and Reduced Ejection Fraction

“…Previous studies have reported that multivessel coronary artery disease, mean gradient <20 mm Hg, absence of LV flow reserve on dobutamine stress echocardiography, peak stress LVEF <35%, and more severe stenosis on dobutamine stress echocardiography are associated with worse outcomes in patients with LF-LG AS (2)(3)(4)(5)8).…”

Transcatheter Aortic Valve Replacement (TAVR) in Low Flow-Low Gradient Severe Aortic Stenosis without Cardiac Reserve

“…In a European Multicenter study, Monin et al similarly reported that absence of CR was a powerful independent predictor of overall mortality in patients with LFLG AS and reported a higher operative mortality (32%) among those treated surgically despite an overall benefit over medical treatment [11]. In a French study, Quere et al showed that despite the higher operative mortality with surgical AVR (SAVR) among with patients with LFLG severe AS with rEF and no CR, those who survived the procedure experienced significant improvement in EF [12]. In conclusion lack of CR does predict high post-operative mortality, but among those who survive, a significant improvement in EF, symptoms and long-term survival may be seen.…”

Parsimonious assessment for reoperative aortic valve replacement; the deterrent effect of low left ventricular ejection fraction and renal impairment

“…Unfortunately, Dobutamine stress results were seldom available in our study. However, the underlying inotropic reserve does not predict ventricular recovery in patients who survive the AVR (25), and could be less important in the assessment of long-term outcomes.…”