LONG TERM SURVIVAL AFTER AORTIC VALVE
REPLACEMENT IN PATIENTS WITH LOW GRADIENT SEVERE AORTIC STENOSIS AND SEVERE
LEFT VENTRICULAR SYSTOLIC DYSFUNCTION J.J. Pereira*, C.R. Asher, E.H. Blackstone, P.M. McCarthy, J.D.
Thomas, M. Lauer, J.B. Young, I. Afridi. The
Cleveland Clinic Foundation, Cleveland, Ohio, USA. Objectives: The benefit of aortic valve replacement (AVR) for
patients with severe aortic stenosis (AS) and low transvalvular gradients in
the presence of severe left ventricular (LV) systolic dysfunction remains
uncertain. Previous reports of AVR in
this high-risk group show high short and long-term mortality. Methods: We identified 64
consecutive patients who underwent AVR between 1990 to 1998 with aortic valve
area (AVA) < 0.75 cm2, mean gradient < 30mmHg and left ventricular
ejection fraction (LVEF) £ 35%. Clinical,
echocardiograpic, cardiac catheterization and surgical variables were analysed
and patients followed for a mean of 2.8 ± 2.3years. Results: There were 53
males/11 females, age = 70 ± 9 years, 53%
with prior myocardial infarction and 31% with prior coronary artery bypass
surgery (CABG). Echocardiographic factors included: LVEF = 22 ± 6%, AVA=0.62 ± 0.11cm2, and
peak/mean gradients of 43 ± 8 and 25 ± 8 mmHg, respectively.
Severe coronary artery disease (> 2 vessel disease or left main)
occurred in 66% and CABG was performed in 61% of patients. In-hospital
mortality was 4.8%. By Kaplan-Meier analysis, 1-year survival was 84% and
5-year survival was 64%. Long-term univariate predictors of mortality were age,
relative risk (RR) =1.07 (95% CI = 1.01-1.14, p=0.03), insulin dependent
diabetes mellitus RR=3.1 (95% CI = 1.01-9.79, p=0.048) and right ventricular
dysfunction RR=3.0 (95% CI=1.2-7.5, p=0.02). Clinical follow-up was available in
43 of 45 long-term survivors. Mean NYHA functional class improved from 2.9 to
1.6 (p<0.001) and NYHA III/IV functional class decreased from 64% to 19%. Conclusion: AVR for patients with severe low transvalvular
gradient AS and severe LV systolic dysfunction can be performed with acceptable
in-hospital mortality, favourable 1 and 5-year survival and a significant
improvement in NYHA functional class.
