Transcatheter aortic valve implantation in low flow/Low gradient severe aortic stenosis

Abstract

Objectives: To identify predictors of mortality, functional status, and hemodynamical changes of patients undergoing transcatheter aortic valve implantation (TAVI) for low flow/low gradient aortic stenosis (LF/LG AS). Background: There is little published data regarding the outcomes of patients with LF/LG AS following TAVI. Methods: Sixtyeight patients with severe AS, left ventricular dysfunction (ejection fraction [EF] <35%) and low flow (LF) AS underwent TAVI. Patients were stratified according to the aortic mean pressure gradient (low gradient [LG]; with P mean 40 mm Hg and high gradient [HG]: P mean >40 mm Hg). The baseline parameters and clinical outcomes were subsequently compared among the two groups. Cox proportional hazards were used to identify predictors of 6-month mortality. Results: There were 38 patients in the LG group and 30 patients in the HG group. There were no significant difference in 30-day mortality between the two groups. The 6-month and 1-year mortality, however, was 3.8-fold and 2.8-fold higher in the LG group than in the HG group (37.8% vs. 10.3%, P 5 0.01 and 37.8% vs. 13.3%, respectively, P 5 0.01). Univariable predictors for 6-month mortality were: STS Score, aortic valve area, and aortic mean pressure gradient. However, only STS Score (HR 1.08, 1.04-1.12, P < 0.001) remained as independent predictor in the multivariable analysis. Six months after TAVI, hemodynamical (EF > 50%) and clinical (NYHA class I) improvements were shown in both HG and LG groups. Conclusions: LF/LG AS does not influence procedural mortality after TAVI but exhibits a strong impact on 6-month and 1-year mortality. The survivors, however, exhibit considerable hemodynamical and clinical improvements. Therefore, risk stratification and TAVI benefit should be weighted in every patient with LF/LG AS. V C 2014 Wiley Periodicals, Inc.

Assessment of wall stresses and mechanical heart power in the left ventricle: Finite element modeling versus Laplace analysis

“…2 However, re-stenosis frequently occurs, and despite a successful reduction of transvalvular pressure gradients, a majority of patients remains hypertensive, consequently showing increased risk for irreversible course of HF and higher morbidity and mortality. 3 Thus, a successful reduction of pathologically elevated pressure gradients alone cannot be considered a reliable prognostic marker of long-term post-treatment outcomes in these patient cohorts. As a consequence, alternative biomarkers beyond pressure gradients are sought to that provide a complementary view of cardiac function and, potentially, offer a higher predictive power with regard to outcomes.…”

Low‐flow/low‐gradient aortic stenosis—Still a diagnostic and therapeutic challenge

“…In a small substudy (n = 68) by Elhmidi et al, patients with LF/LGAS and an LVEF <35% had a higher 6-month and 1-year mortality compared with patients with HG AS (1-year mortality: 37% vs 13%, respectively). 21 Comparing medical treatment, TAVI, and SAVR in patients with LF/LGAS with low LVEF vs HG AS, Ben-Dor et al likewise showed that patients with classic LF/LGAS had a higher risk for a worse outcome regardless of the treatment option. 22 Comparing TAVI with SAVR, Ben-Dor et al suggested that TAVI may be associated with better and faster LVEF recovery after intervention.…”