Comparison of Outcome of Higher Versus Lower Transvalvular Gradients in Patients With Severe Aortic Stenosis and Low (&lt;40%) Left Ventricular Ejection Fraction

Ben‐Dor, Itsik; Maluenda, Gabriel; Iyasu, Getachew D.; Laynez-Carnicero, Ana; Hauville, Camille; Torguson, Rebecca; Okubagzi, Petros; Zhang, Xue; Goldstein, Steven A.; Lindsay, Joseph; Satler, Lowell F.; Pichard, Augusto D.; Waksman, Ron

doi:10.1016/j.amjcard.2011.11.041

Cited by 35 publications

(38 citation statements)

References 18 publications

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“…9 Observational studies showed that patients with severe aortic stenosis and low LVEF with low MTG are at higher risk for worse outcomes compared with patients with high transvalvular gradient both after SAVR and TAVI. 10,21 This may be because of several factors: actually from one side, these patients may represent a final stage of the disease, with dilated ventricles without sufficient contractile strength to open the valve, and from the other side, they may be the consequence of other mechanisms, like severe coronary artery disease.…”

Section: Discussionmentioning

confidence: 98%

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Transcatheter aortic valve implantation in low ejection fraction/low transvalvular gradient patients

Conrotto

D’Ascenzo

Stella

et al. 2017

Journal of Cardiovascular Medicine

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Section: Discussionmentioning

confidence: 98%

“…These findings are consistent with all recent studies. 10,11,21 The management of patients with low LVEF and low MTG represents a true clinical challenge. In this 4 Journal of Cardiovascular Medicine 2016, Vol 00 No 00 high-risk subgroup, an evaluation of preprocedural contractile reserve may add important insights regarding outcomes.…”

Section: Discussionmentioning

confidence: 99%

Transcatheter aortic valve implantation in low ejection fraction/low transvalvular gradient patients

Conrotto

D’Ascenzo

Stella

et al. 2017

Journal of Cardiovascular Medicine

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“…Several studies have shown that low-gradient severe AS is associated with an increased risk for overall mortality [8,9,10,11,12], whereas other studies have shown similar overall mortality in patients with either low- or high-gradient severe AS [13,14,15]. Most previous works analyzed AVG as a dichotomized variable; only three trials [10,12,15] evaluated AVG as a continuous variable: Kodali et al [10] analyzed 2-year outcomes of 348 patients in the arm of the PARTNER trial and found that each increment of 10 mm Hg in mean AVG was associated with an adjusted reduction of 18% in 2-year mortality (p = 0.003).…”

Section: Discussionmentioning

confidence: 99%

“…Among patients undergoing surgical aortic valve replacement, those with low-gradient AS are known to have an increased risk of mortality [7]. In the TAVI population, most [8,9,10,11,12] but not all [13,14,15] studies found low-gradient AS to be associated with an increased risk for overall mortality. Of these trials, only 3 [10,12,15] evaluated AVG as a continuous variable, and none evaluated the prognostic impact of AVG as a continuous variable in patients with preserved left-ventricular (LV) function and high-gradient AS.…”

Section: Introductionmentioning

confidence: 99%

Aortic Valve Gradient and Clinical Outcome in Patients Undergoing Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis

et al. 2016

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Objectives: To explore the relation between the baseline aortic valve gradient (AVG) as a continuous variable and clinical outcomes following transcatheter aortic valve implantation (TAVI) in general and specifically in patients with high-gradient aortic stenosis (AS). Methods: We reviewed 317 consecutive patients who underwent TAVI at our institution. We investigated the relation between AVG as a continuous/categorical variable and outcome among all patients and in patients without low-flow low-gradient AS, using the Cox proportional hazard model adjusting for multiple prognostic variables. Results: Patients had a peak AVG of 79.9 ± 22.8 mm Hg (mean 50.5 ±15.7). During a mean follow-up of 2.7 years, AVG was inversely associated with mortality and mortality or cardiac hospitalization. Every 10-mm-Hg increase in peak AVG was associated with 18% reduction in mortality (p = 0.003) and 19% reduction in mortality/cardiac hospitalization (p < 0.001). Every 10-mm-Hg increase in mean AVG was associated with a 24% reduction in both outcomes (p = 0.005 and p < 0.001). Subgroup analysis of patients with left-ventricular ejection fraction >40% or peak AVG >64 mm Hg yielded similar results. Conclusions: Mean and peak baseline AVGs are directly associated with improved outcomes after TAVI; AVG can be used to select the patients most likely to benefit from TAVI.

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“…1,2,6,10,11 Transcatheter aortic valve implantation (TAVI) is a less invasive alternative procedure to SAVR for the treatment of high-risk patients presenting with symptomatic severe AS. 12,13 Several studies have demonstrated the feasibility of TAVI to treat patients with symptomatic LEF-LG severe AS, 7,9,[14][15][16][17] which is reflected in the recent 2014 American Heart Association/American College of Cardiology guidelines providing a class IIa recommendation for TAVI for the treatment of symptomatic LEF-LG in high-risk patients.…”

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confidence: 99%

Impact of Mitral Regurgitation on Clinical Outcomes of Patients With Low-Ejection Fraction, Low-Gradient Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation

O’Sullivan

Stortecky

Bütikofer

et al. 2015

Circ: Cardiovascular Interventions

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LEF-LG is present in ≈5% to 10% of the overall population of patients with severe AS. 6 However, the prevalence of LEF-LG among patients undergoing TAVI is higher (10% to 16%) because of the predominance of high-risk patients. 7,9,14,15 Moderate to severe mitral regurgitation (MR) is present in 2% to 22% of unselected patients undergoing TAVI, [19][20][21][22] whereas its prevalence in LEF-LG patients undergoing TAVI is considerably higher (20% to 55%). 7,9,14,15 Recently, several conflictingBackground-Up to 1 in 6 patients undergoing transcatheter aortic valve implantation (TAVI) present with low-ejection fraction, low-gradient (LEF-LG) severe aortic stenosis and concomitant relevant mitral regurgitation (MR) is present in 30% to 55% of these patients. The effect of MR on clinical outcomes of LEF-LG patients undergoing TAVI is unknown. Methods and Results-Of 606 consecutive patients undergoing TAVI, 113 (18.7%) patients with LEF-LG severe aortic stenosis (mean gradient ≤40 mm Hg, aortic valve area <1.0 cm 2 , left ventricular ejection fraction <50%) were analyzed. LEF-LG patients were dichotomized into ≤mild MR (n=52) and ≥moderate MR (n=61). Primary end point was all-cause mortality at 1 year. No differences in mortality were observed at 30 days (P=0.76). At 1 year, LEF-LG patients with ≥moderate MR had an adjusted 3-fold higher rate of all-cause mortality (11.5% versus 38.1%; adjusted hazard ratio, 3.27 [95% confidence interval, 1.31-8.15]; P=0.011), as compared with LEF-LG patients with ≤mild MR. Mortality was mainly driven by cardiac death (adjusted hazard ratio, 4.62; P=0.005). As compared with LEF-LG patients with ≥moderate MR assigned to medical therapy, LEF-LG patients with ≥moderate MR undergoing TAVI had significantly lower all-cause mortality (hazard ratio, 0.38; 95% confidence interval, 0.019-0.75) at 1 year. Conclusions-Moderate or severe MR is a strong independent predictor of late mortality in LEF-LG patients undergoing TAVI.However, LEF-LG patients assigned to medical therapy have a dismal prognosis independent of MR severity suggesting that TAVI should not be withheld from symptomatic patients with LEF-LG severe aortic stenosis even in the presence of moderate or severe MR. (Circ Cardiovasc Interv. 2015;8:e001895.

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Comparison of Outcome of Higher Versus Lower Transvalvular Gradients in Patients With Severe Aortic Stenosis and Low (<40%) Left Ventricular Ejection Fraction

Cited by 35 publications

References 18 publications

Transcatheter aortic valve implantation in low ejection fraction/low transvalvular gradient patients

Transcatheter aortic valve implantation in low ejection fraction/low transvalvular gradient patients

Aortic Valve Gradient and Clinical Outcome in Patients Undergoing Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis

Impact of Mitral Regurgitation on Clinical Outcomes of Patients With Low-Ejection Fraction, Low-Gradient Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation

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