Clinical outcomes and revascularization strategies in patients with low-flow, low-gradient severe aortic valve stenosis according to the assigned treatment modality

O'Sullivan, Crochan J.; Englberger, Lars; Hosek, Nicola; Heg, Dik; Cao, Davide; Stefanini, Giulio; Stortecky, Stefan; Glökler, Steffen; Spitzer, Ernest; Tüller, David; Huber, Christoph; Pilgrim, Thomas; Praz, Fabien; Büllesfeld, Lutz; Khattab, Ahmed A.; Carrel, Thierry; Meier, Bernhard; Windecker, Stephan; Wenaweser, Peter Martin (2015). Clinical outcomes and revascularization strategies in patients with low-flow, low-gradient severe aortic valve stenosis according to the assigned treatment modality. JACC. Cardiovascular Interventions, 8(5), pp. 704-717. Elsevier 10.1016/j.jcin.2014.11.020

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OBJECTIVES

This study compared clinical outcomes and revascularization strategies among patients presenting with low ejection fraction, low-gradient (LEF-LG) severe aortic stenosis (AS) according to the assigned treatment modality.

BACKGROUND

The optimal treatment modality for patients with LEF-LG severe AS and concomitant coronary artery disease (CAD) requiring revascularization is unknown.

METHODS

Of 1,551 patients, 204 with LEF-LG severe AS (aortic valve area <1.0 cm(2), ejection fraction <50%, and mean gradient <40 mm Hg) were allocated to medical therapy (MT) (n = 44), surgical aortic valve replacement (SAVR) (n = 52), or transcatheter aortic valve replacement (TAVR) (n = 108). CAD complexity was assessed using the SYNTAX score (SS) in 187 of 204 patients (92%). The primary endpoint was mortality at 1 year.

RESULTS

LEF-LG severe AS patients undergoing SAVR were more likely to undergo complete revascularization (17 of 52, 35%) compared with TAVR (8 of 108, 8%) and MT (0 of 44, 0%) patients (p < 0.001). Compared with MT, both SAVR (adjusted hazard ratio [adj HR]: 0.16; 95% confidence interval [CI]: 0.07 to 0.38; p < 0.001) and TAVR (adj HR: 0.30; 95% CI: 0.18 to 0.52; p < 0.001) improved survival at 1 year. In TAVR and SAVR patients, CAD severity was associated with higher rates of cardiovascular death (no CAD: 12.2% vs. low SS [0 to 22], 15.3% vs. high SS [>22], 31.5%; p = 0.037) at 1 year. Compared with no CAD/complete revascularization, TAVR and SAVR patients undergoing incomplete revascularization had significantly higher 1-year cardiovascular death rates (adj HR: 2.80; 95% CI: 1.07 to 7.36; p = 0.037).

CONCLUSIONS

Among LEF-LG severe AS patients, SAVR and TAVR improved survival compared with MT. CAD severity was associated with worse outcomes and incomplete revascularization predicted 1-year cardiovascular mortality among TAVR and SAVR patients.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of Intensive Care, Emergency Medicine and Anaesthesiology (DINA) > Clinic and Policlinic for Anaesthesiology and Pain Therapy
04 Faculty of Medicine > Department of Cardiovascular Disorders (DHGE) > Clinic of Cardiovascular Surgery
04 Faculty of Medicine > Department of Cardiovascular Disorders (DHGE) > Clinic of Cardiology
04 Faculty of Medicine > Pre-clinic Human Medicine > CTU Bern
04 Faculty of Medicine > Pre-clinic Human Medicine > Institute of Social and Preventive Medicine (ISPM)

UniBE Contributor:

O'Sullivan, Crochan John, Englberger, Lars, Heg, Dierik Hans, Stefanini, Giulio, Stortecky, Stefan, Glökler, Steffen, Huber, Christoph, Pilgrim, Thomas, Praz, Fabien Daniel, Büllesfeld, Lutz, Khattab, Ahmed Aziz, Carrel, Thierry, Meier, Bernhard, Windecker, Stephan, Wenaweser, Peter Martin

Subjects:

600 Technology > 610 Medicine & health
300 Social sciences, sociology & anthropology > 360 Social problems & social services

ISSN:

1876-7605

Publisher:

Elsevier

Language:

English

Submitter:

Jeannie Wurz

Date Deposited:

14 Dec 2015 11:17

Last Modified:

02 Mar 2023 23:26

Publisher DOI:

10.1016/j.jcin.2014.11.020

PubMed ID:

25946444

Uncontrolled Keywords:

aortic stenosis; coronary artery disease; surgical aortic valve replacement; transcatheter aortic valve replacement

BORIS DOI:

10.7892/boris.74082

URI:

https://boris.unibe.ch/id/eprint/74082

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