Victor Dayan1, Gustavo Vignolo2, Julien Magne3, Marie-Annick Clavel4, Dania Mohty3, Philippe Pibarot5. 1. Centro Cardiovascular, Hospital de Clinicas, Universidad de la Republica, Montevideo, Uruguay. Electronic address: victor_dayan@hotmail.com. 2. Centro Cardiovascular, Hospital de Clinicas, Universidad de la Republica, Montevideo, Uruguay. 3. Centre Hospitalier Universitaire de Limoges, Limoges, France. 4. Québec Heart and Lung Institute, Laval University, Quebec, Canada. 5. Québec Heart and Lung Institute, Laval University, Quebec, Canada. Electronic address: philippe.pibarot@med.ulaval.ca.
Abstract
BACKGROUND: Low mean transvalvular gradient (<40 mm Hg) and small aortic valve area (<1.0 cm(2)) in patients with aortic stenosis (AS) and preserved left ventricular ejection fraction raises uncertainty about the actual severity of the stenosis and survival benefit of aortic valve replacement (AVR). OBJECTIVES: This study analyzed studies of mortality and survival impact of AVR in patients with low-gradient (LG) AS and preserved left ventricular ejection fraction, including paradoxical low-flow (i.e., stroke volume index <35 ml/m(2)), low-gradient (LF-LG) and normal-flow, low-gradient (NF-LG), and those with high-gradient (≥ 40 mm Hg) AS or moderate AS. METHODS: Studies published between 2005 and 2015 were analyzed. Primary outcome was the survival benefit associated with AVR. Secondary outcome was overall mortality regardless of treatment. RESULTS: Eighteen studies were included in the analysis. Patients with LF-LG AS have increased mortality compared with patients with moderate AS (hazard ratio [HR]: 1.68; 95% confidence interval [CI]: 1.31 to 2.17), NF-LG (HR: 1.80; 95% CI: 1.29 to 2.51), and high-gradient (HR: 1.67; 95% CI: 1.16 to 2.39) AS. AVR was associated with reduced mortality in patients with LF-LG (HR: 0.44; 95% CI: 0.25 to 0.77). Similar benefit occurred with AVR in patients with NF-LG (HR: 0.48; 95% CI: 0.28 to 0.83). Compared with patients with high-gradient AS, those with LF-LG were less likely to be referred to AVR (odds ratio: 0.32; 95% CI: 0.21 to 0.49). CONCLUSIONS: Patients with paradoxical LF-LG AS and NF-LG AS have increased risk of mortality compared with other subtypes of AS with preserved left ventricular ejection fraction, and improved outcome with AVR.
BACKGROUND: Low mean transvalvular gradient (<40 mm Hg) and small aortic valve area (<1.0 cm(2)) in patients with aortic stenosis (AS) and preserved left ventricular ejection fraction raises uncertainty about the actual severity of the stenosis and survival benefit of aortic valve replacement (AVR). OBJECTIVES: This study analyzed studies of mortality and survival impact of AVR in patients with low-gradient (LG) AS and preserved left ventricular ejection fraction, including paradoxical low-flow (i.e., stroke volume index <35 ml/m(2)), low-gradient (LF-LG) and normal-flow, low-gradient (NF-LG), and those with high-gradient (≥ 40 mm Hg) AS or moderate AS. METHODS: Studies published between 2005 and 2015 were analyzed. Primary outcome was the survival benefit associated with AVR. Secondary outcome was overall mortality regardless of treatment. RESULTS: Eighteen studies were included in the analysis. Patients with LF-LG AS have increased mortality compared with patients with moderate AS (hazard ratio [HR]: 1.68; 95% confidence interval [CI]: 1.31 to 2.17), NF-LG (HR: 1.80; 95% CI: 1.29 to 2.51), and high-gradient (HR: 1.67; 95% CI: 1.16 to 2.39) AS. AVR was associated with reduced mortality in patients with LF-LG (HR: 0.44; 95% CI: 0.25 to 0.77). Similar benefit occurred with AVR in patients with NF-LG (HR: 0.48; 95% CI: 0.28 to 0.83). Compared with patients with high-gradient AS, those with LF-LG were less likely to be referred to AVR (odds ratio: 0.32; 95% CI: 0.21 to 0.49). CONCLUSIONS:Patients with paradoxical LF-LG AS and NF-LG AS have increased risk of mortality compared with other subtypes of AS with preserved left ventricular ejection fraction, and improved outcome with AVR.
Authors: Suzanne J Baron; Suzanne V Arnold; Howard C Herrmann; David R Holmes; Wilson Y Szeto; Keith B Allen; Adnan K Chhatriwalla; Sreekaanth Vemulapali; Sean O'Brien; Dadi Dai; David J Cohen Journal: J Am Coll Cardiol Date: 2016-05-24 Impact factor: 24.094
Authors: Brian R Lindman; Marie-Annick Clavel; Patrick Mathieu; Bernard Iung; Patrizio Lancellotti; Catherine M Otto; Philippe Pibarot Journal: Nat Rev Dis Primers Date: 2016-03-03 Impact factor: 52.329