Transcatheter aortic valve replacement and standard therapy in inoperable patients with aortic stenosis and low EF

Passeri, Jonathan J.; Elmariah, Sammy; Xu, Ke; Inglessis, Ignacio; Baker, Joshua N.; Alu, Maria; Kodali, Susheel; Leon, Martin B.; Svensson, Lars G.; Pîbarot, Philippe; Fearon, William F.; Kirtane, Ajay J.; Vlahakes, Gus J.; Palacios, Igor F.; Douglas, Pamela S.; Investigators, Partner

doi:10.1136/heartjnl-2014-306737

Cited by 43 publications

(34 citation statements)

References 30 publications

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“…1,11 Although these studies included patients with lesser degrees of LV systolic dysfunction (ie, EF 40%-50%), the general finding of a rapid recovery is similar: in PARTNER A, ≈50% of patients demonstrated early LVEF recovery (≥10% absolute increase in EF at 30-day follow-up after Sapien TAVR). Our finding of a high rate (62%) of early LVEF recovery may portend a role for the CoreValve TAVR procedure in these patients with low EF.…”

Section: Temporal Trends In Recovery Of Lvefmentioning

confidence: 88%

“…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%

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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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Section: Temporal Trends In Recovery Of Lvefmentioning

confidence: 88%

Section: Recovery Of Lvef: Time and Predictorsmentioning

confidence: 99%

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confidence: 99%

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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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“…& We found that a subset of patients treated with standard therapy within the PARTNER trial experienced significant improvement in LV systolic function, symptoms, and 1-year survival. This observation was hypothesized to be due to the temporary benefits seen with BAV [72], although in the entire cohort, BAV was not associated with improvements in LV function [97•]. Importantly, benefits observed after BAV did not persist beyond 1 year, emphasizing the need for definitive therapy with AVR.…”

Section: Balloon Aortic Valvuloplastymentioning

confidence: 94%

Patterns of Left Ventricular Remodeling in Aortic Stenosis: Therapeutic Implications

Elmariah

2015

Curr Treat Options Cardio Med

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Aortic valve stenosis is characterized by indolent progression followed by the late development of symptoms once left ventricular compensatory mechanisms fail. In this review, we describe the left ventricular response to aortic stenosis. Specifically, we highlight the process of adaptive remodeling, which begins as a beneficial compensatory mechanism but ultimately transitions to a maladaptive process characterized by inappropriate left ventricular hypertrophy, interstitial fibrosis, and diminished contractility. Myocardial fibrosis ensues as the remodeling process progresses with potentially irreversible consequences on diastolic and systolic function and on clinical symptoms and outcomes. Recent data suggest that fibrosis is largely responsible for the development of symptoms in patients with severe aortic stenosis, which unfortunately implies that fibrosis may be advanced by the time clinical symptomatology triggers evaluation for aortic valve replacement. Interstitial fibrosis persists for years after valve replacement and, when severe, can lessen the clinical benefits of valve replacement. Further evaluation of noninvasive measures capable of assessing the extent of maladaptive left ventricular remodeling and of predicting its reversal are desperately needed in order to enhance the personalized delivery of aortic valve replacement for severe aortic stenosis. We support aggressive assessment of symptomatic status with more frequent clinical follow-up and exercise testing in asymptomatic individuals with severe left ventricular hypertrophy or impaired longitudinal contractility. However, whether early valve replacement is advantageous in patients with evidence of maladaptive left ventricular remodeling in the absence of symptoms remains unknown, but is certainly worthy of further investigation.

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“…Passeri et al showed effectiveness of transfemoral TAVR in improving survival among patients with mild-moderate LV dysfunction (EF >20%) and inoperable AS compared to standard medical therapy [16]. In a meta-analysis of 7,673 patients with severe AS who underwent TAVR, patients with a low stroke volume index (< 35ml/m2), low gradient and low EF (< 30%) had significant higher mortality at follow up.…”

Section: Discussionmentioning

confidence: 99%

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

Sudhakaran¹,

Shah

Aparna³

et al. 2017

J.ATAMIS

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With accumulating positive evidence in favour of transcatheter aortic valve replacement (TAVR) over a surgical approach, it has replaced surgical AVR to become the mainstay of treatment for severe symptomatic aortic stenosis in patients with prohibitive and high surgical risk. There is significant surgical mortality and morbidity associated with surgical aortic valve replacement in patients with low flow-low gradient (LFLG) true severe aortic valve stenosis (AS) and severely reduced left ventricular ejection fraction (rEF) without contractile reserve (CR). CR is measured following use of dobutamine in an attempt to increase cardiac output by more than 20% while differentiating severe from pseudostenosis in some cases. The value of transcatheter aortic valve replacement (TAVR) over a surgical approach for these patients with rEF LFLG true severe AS and no CR is uncertain. We present a patient with LFLG severe AS and low left ventricular EF without contractile reserve who underwent TAVR and experienced significant improvement in their clinical status without complications.

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Transcatheter aortic valve replacement and standard therapy in inoperable patients with aortic stenosis and low EF

Abstract: ClinicalTrials.gov Unique Identifier #NCT00530894.

Cited by 43 publications

References 30 publications

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

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

Patterns of Left Ventricular Remodeling in Aortic Stenosis: Therapeutic Implications

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

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