OBJECTIVES: This study investigated whether aortic valve replacement (AVR) is associated with improved survival in patients with severe low-flow/low-gradient aortic stenosis (LF/LGAS) without contractile reserve (CR) on dobutamine stress echocardiography (DSE). BACKGROUND: Patients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial. METHODS: Eighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area <or=1 cm(2), left ventricular ejection fraction <or=40%, mean pressure gradient [MPG] <or=40 mm Hg) without CR on DSE were enrolled. Absence of CR was defined as the absence of increase in stroke volume of >or=20% compared with the baseline value. Multivariable analysis and propensity scores were used to compare survival according to whether or not AVR was performed (n = 55). RESULTS: Five-year survival was higher in AVR patients compared with medically managed patients (54 +/- 7% vs. 13 +/- 7%, p = 0.001) despite a high operative mortality of 22% (n = 12). An AVR was independently associated with lower 5-year mortality (adjusted hazard ratio from 0.16 to 5.21 varying with time [95% confidence interval: 0.12-3.16 to 0.21-8.50], p = 0.00026). In 42 propensity-matched patients, 5-year survival was markedly improved by AVR (65 +/- 11% vs. 11 +/- 7%, p = 0.019). Associated bypass surgery (p = 0.007) and MPG <or=20 mm Hg (p = 0.035) were independently predictive of operative mortality. Late survival after AVR (excluding operative death) was 69 +/- 8% at 5 years. CONCLUSIONS: In patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.
OBJECTIVES: This study investigated whether aortic valve replacement (AVR) is associated with improved survival in patients with severe low-flow/low-gradient aortic stenosis (LF/LGAS) without contractile reserve (CR) on dobutamine stress echocardiography (DSE). BACKGROUND:Patients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial. METHODS: Eighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area <or=1 cm(2), left ventricular ejection fraction <or=40%, mean pressure gradient [MPG] <or=40 mm Hg) without CR on DSE were enrolled. Absence of CR was defined as the absence of increase in stroke volume of >or=20% compared with the baseline value. Multivariable analysis and propensity scores were used to compare survival according to whether or not AVR was performed (n = 55). RESULTS: Five-year survival was higher in AVR patients compared with medically managed patients (54 +/- 7% vs. 13 +/- 7%, p = 0.001) despite a high operative mortality of 22% (n = 12). An AVR was independently associated with lower 5-year mortality (adjusted hazard ratio from 0.16 to 5.21 varying with time [95% confidence interval: 0.12-3.16 to 0.21-8.50], p = 0.00026). In 42 propensity-matched patients, 5-year survival was markedly improved by AVR (65 +/- 11% vs. 11 +/- 7%, p = 0.019). Associated bypass surgery (p = 0.007) and MPG <or=20 mm Hg (p = 0.035) were independently predictive of operative mortality. Late survival after AVR (excluding operative death) was 69 +/- 8% at 5 years. CONCLUSIONS: In patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.
Authors: Frédéric Maes; Stamatios Lerakis; Henrique Barbosa Ribeiro; Martine Gilard; João L Cavalcante; Raj Makkar; Howard C Herrmann; Stephan Windecker; Maurice Enriquez-Sarano; Asim N Cheema; Luis Nombela-Franco; Ignacio Amat-Santos; Antonio J Muñoz-García; Bruno Garcia Del Blanco; Alan Zajarias; John C Lisko; Salim Hayek; Vasilis Babaliaros; Florent Le Ven; Thomas G Gleason; Tarun Chakravarty; Wilson Szeto; Marie-Annick Clavel; Alberto de Agustin; Vicenç Serra; John T Schindler; Abdellaziz Dahou; Mohammed Salah-Annabi; Emilie Pelletier-Beaumont; Melanie Côté; Rishi Puri; Philippe Pibarot; Josep Rodés-Cabau Journal: JAMA Cardiol Date: 2019-01-01 Impact factor: 14.676