Aortic valve replacement improves survival in severe aortic stenosis with gradient–area mismatch

• Published in: European journal of cardio-thoracic surgery Vol. 53; no. 3; pp. 569 - 575
• Main Authors: Mo, Yujing, Van Camp, Guy, Di Gioia, Giuseppe, Barbato, Emanuele, Ondrus, Tomas, Casselman, Filip, Vanderheyden, Marc, De Bruyne, Bernard, Bartunek, Jozef, Penicka, Martin
• Format: Journal Article
• Language: English
• Published: Germany Oxford University Press 01-03-2018
• Subjects: Aged; Aged, 80 and over; Aortic Valve - surgery; Aortic Valve Stenosis - diagnosis; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - surgery; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation - methods; Heart Valve Prosthesis Implantation - mortality; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Prognosis; Retrospective Studies; Treatment Outcome; Aortic stenosis; Aortic valve replacement; Prognosis; Survival
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1093/ejcts/ezx362

Abstract
OBJECTIVES
To investigate whether and in which patients with catheter-derived low pressure gradient (PG, <40 mmHg) severe (aortic valve area ≤ 1 cm2) aortic stenosis and preserved left ventricular ejection fraction, early aortic valve replacement (AVR) might improve survival.
METHODS
We investigated a total of 506 consecutive patients (age 75 ± 9 years, 58% men) with either moderate aortic stenosis (MAS) or severe aortic stenosis (SAS) and preserved left ventricular ejection fraction (≥50%) as defined at catheterization. Propensity score matching was used to select matched pairs of patients with and without AVR in each group. A 100% complete follow-up of all cause death was obtained after a median of 6.6 years (interquartile range 3.4–8.8 years).
RESULTS
There were 62 (12%) patients with MAS, 119 (24%) patients with SAS and low (<40 mmHg) PG and 325 (64%) patients with SAS and high PG. Significantly less patients with MAS and low-gradient SAS underwent AVR compared to patients with high gradient SAS (58% vs 60% vs 83%, P < 0.001). In propensity score-matched patients, AVR was independently associated with a decrease in all-cause mortality in all groups (P < 0.05) regardless of the PG, stroke volume or aortic valve area.
CONCLUSIONS
The present data indicate a that AVR improves survival in SAS regardless of the gradient and flow. This advocates an ‘early-AVR’ rather than a ‘watchful waiting’ strategy.