Effect of left ventricular ejection fraction on postoperative outcome in patients with severe aortic stenosis undergoing aortic valve replacement

Jordi S. Dahl, Mackram Eleid, Hector I Michelena, Christopher G. Scott, Rakesh M. Suri, Hartzell V Schaff, Patricia Pellikka

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Abstract

Background - In asymptomatic patients with severe aortic stenosis, guidelines recommend left ventricular ejection fraction (LVEF) of <50% as the threshold for referral for aortic valve replacement. We investigated the importance of LVEF on long-term outcome after aortic valve replacement in symptomatic and asymptomatic patients with severe aortic stenosis. Methods and Results - We retrospectively identified 2017 patients with severe aortic stenosis (aortic valve area<1 cm<sup>2</sup>, mean gradient≥40 mm Hg, or indexed aortic valve area<0.6 cm<sup>2</sup>/m<sup>2</sup>) who underwent surgical aortic valve replacement from January 1995 to June 2009. Patients were divided into 4 groups depending on preoperative LVEF (<50% in 300 [15%] patients, 50%-59% in 331 [17%], 60%-69% in 908 [45%], and ≥70% in 478 [24%]). During follow-up of 5.3±4.4 years, 1056 (52%) patients died. A decrease in mortality was observed with increasing LVEF, P<0.0001; 5-year mortality estimates (95% confidence interval) were 0.41 (0.35-0.47), LVEF<50%; 0.35 (0.29-0.41), LVEF 50% to 59%; 0.26 (0.23-0.29), LVEF 60% to 69%; and 0.22 (0.18-0.26), LVEF≥70%. Compared with patients with LVEF≥60%, patients with LVEF 50% to 59% had increased mortality (hazard ratio [HR], 1.58; P<0.001), with similar risk increase in both symptomatic (HR, 1.56; P<0.001) and asymptomatic patients (HR, 1.58; P=0.006). Correcting for risk factors, LV mass index, aortic valve area, and stroke volume index, LVEF was independently predictive of mortality (HR, 0.88 per 10%; P<0.001). When this analysis was repeated in the subset of 1333 patients without history of coronary artery disease, LVEF remained associated with mortality (HR, 0.90 per 10%; P=0.009). Conclusions - LVEF is a powerful predictor of outcome in patients with severe aortic stenosis undergoing aortic valve replacement, independent of the presence of valve-related symptoms.

Original languageEnglish (US)
Article numbere002917
JournalCirculation: Cardiovascular Imaging
Volume8
Issue number4
DOIs
StatePublished - Apr 22 2015

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Aortic Valve Stenosis
Aortic Valve
Stroke Volume
Mortality
Surgical Instruments
Coronary Artery Disease
Guidelines
Confidence Intervals

Keywords

  • aortic valve
  • aortic valve stenosis
  • cardiac surgical procedures
  • echocardiography
  • ventricular remodeling

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Radiology Nuclear Medicine and imaging
  • Medicine(all)

Cite this

@article{5fa5bb817aaa46138f03f667302bc023,
title = "Effect of left ventricular ejection fraction on postoperative outcome in patients with severe aortic stenosis undergoing aortic valve replacement",
abstract = "Background - In asymptomatic patients with severe aortic stenosis, guidelines recommend left ventricular ejection fraction (LVEF) of <50{\%} as the threshold for referral for aortic valve replacement. We investigated the importance of LVEF on long-term outcome after aortic valve replacement in symptomatic and asymptomatic patients with severe aortic stenosis. Methods and Results - We retrospectively identified 2017 patients with severe aortic stenosis (aortic valve area<1 cm2, mean gradient≥40 mm Hg, or indexed aortic valve area<0.6 cm2/m2) who underwent surgical aortic valve replacement from January 1995 to June 2009. Patients were divided into 4 groups depending on preoperative LVEF (<50{\%} in 300 [15{\%}] patients, 50{\%}-59{\%} in 331 [17{\%}], 60{\%}-69{\%} in 908 [45{\%}], and ≥70{\%} in 478 [24{\%}]). During follow-up of 5.3±4.4 years, 1056 (52{\%}) patients died. A decrease in mortality was observed with increasing LVEF, P<0.0001; 5-year mortality estimates (95{\%} confidence interval) were 0.41 (0.35-0.47), LVEF<50{\%}; 0.35 (0.29-0.41), LVEF 50{\%} to 59{\%}; 0.26 (0.23-0.29), LVEF 60{\%} to 69{\%}; and 0.22 (0.18-0.26), LVEF≥70{\%}. Compared with patients with LVEF≥60{\%}, patients with LVEF 50{\%} to 59{\%} had increased mortality (hazard ratio [HR], 1.58; P<0.001), with similar risk increase in both symptomatic (HR, 1.56; P<0.001) and asymptomatic patients (HR, 1.58; P=0.006). Correcting for risk factors, LV mass index, aortic valve area, and stroke volume index, LVEF was independently predictive of mortality (HR, 0.88 per 10{\%}; P<0.001). When this analysis was repeated in the subset of 1333 patients without history of coronary artery disease, LVEF remained associated with mortality (HR, 0.90 per 10{\%}; P=0.009). Conclusions - LVEF is a powerful predictor of outcome in patients with severe aortic stenosis undergoing aortic valve replacement, independent of the presence of valve-related symptoms.",
keywords = "aortic valve, aortic valve stenosis, cardiac surgical procedures, echocardiography, ventricular remodeling",
author = "Dahl, {Jordi S.} and Mackram Eleid and Michelena, {Hector I} and Scott, {Christopher G.} and Suri, {Rakesh M.} and Schaff, {Hartzell V} and Patricia Pellikka",
year = "2015",
month = "4",
day = "22",
doi = "10.1161/CIRCIMAGING.114.002917",
language = "English (US)",
volume = "8",
journal = "Circulation: Cardiovascular Imaging",
issn = "1941-9651",
publisher = "Lippincott Williams and Wilkins",
number = "4",

}

TY - JOUR

T1 - Effect of left ventricular ejection fraction on postoperative outcome in patients with severe aortic stenosis undergoing aortic valve replacement

AU - Dahl, Jordi S.

AU - Eleid, Mackram

AU - Michelena, Hector I

AU - Scott, Christopher G.

AU - Suri, Rakesh M.

AU - Schaff, Hartzell V

AU - Pellikka, Patricia

PY - 2015/4/22

Y1 - 2015/4/22

N2 - Background - In asymptomatic patients with severe aortic stenosis, guidelines recommend left ventricular ejection fraction (LVEF) of <50% as the threshold for referral for aortic valve replacement. We investigated the importance of LVEF on long-term outcome after aortic valve replacement in symptomatic and asymptomatic patients with severe aortic stenosis. Methods and Results - We retrospectively identified 2017 patients with severe aortic stenosis (aortic valve area<1 cm2, mean gradient≥40 mm Hg, or indexed aortic valve area<0.6 cm2/m2) who underwent surgical aortic valve replacement from January 1995 to June 2009. Patients were divided into 4 groups depending on preoperative LVEF (<50% in 300 [15%] patients, 50%-59% in 331 [17%], 60%-69% in 908 [45%], and ≥70% in 478 [24%]). During follow-up of 5.3±4.4 years, 1056 (52%) patients died. A decrease in mortality was observed with increasing LVEF, P<0.0001; 5-year mortality estimates (95% confidence interval) were 0.41 (0.35-0.47), LVEF<50%; 0.35 (0.29-0.41), LVEF 50% to 59%; 0.26 (0.23-0.29), LVEF 60% to 69%; and 0.22 (0.18-0.26), LVEF≥70%. Compared with patients with LVEF≥60%, patients with LVEF 50% to 59% had increased mortality (hazard ratio [HR], 1.58; P<0.001), with similar risk increase in both symptomatic (HR, 1.56; P<0.001) and asymptomatic patients (HR, 1.58; P=0.006). Correcting for risk factors, LV mass index, aortic valve area, and stroke volume index, LVEF was independently predictive of mortality (HR, 0.88 per 10%; P<0.001). When this analysis was repeated in the subset of 1333 patients without history of coronary artery disease, LVEF remained associated with mortality (HR, 0.90 per 10%; P=0.009). Conclusions - LVEF is a powerful predictor of outcome in patients with severe aortic stenosis undergoing aortic valve replacement, independent of the presence of valve-related symptoms.

AB - Background - In asymptomatic patients with severe aortic stenosis, guidelines recommend left ventricular ejection fraction (LVEF) of <50% as the threshold for referral for aortic valve replacement. We investigated the importance of LVEF on long-term outcome after aortic valve replacement in symptomatic and asymptomatic patients with severe aortic stenosis. Methods and Results - We retrospectively identified 2017 patients with severe aortic stenosis (aortic valve area<1 cm2, mean gradient≥40 mm Hg, or indexed aortic valve area<0.6 cm2/m2) who underwent surgical aortic valve replacement from January 1995 to June 2009. Patients were divided into 4 groups depending on preoperative LVEF (<50% in 300 [15%] patients, 50%-59% in 331 [17%], 60%-69% in 908 [45%], and ≥70% in 478 [24%]). During follow-up of 5.3±4.4 years, 1056 (52%) patients died. A decrease in mortality was observed with increasing LVEF, P<0.0001; 5-year mortality estimates (95% confidence interval) were 0.41 (0.35-0.47), LVEF<50%; 0.35 (0.29-0.41), LVEF 50% to 59%; 0.26 (0.23-0.29), LVEF 60% to 69%; and 0.22 (0.18-0.26), LVEF≥70%. Compared with patients with LVEF≥60%, patients with LVEF 50% to 59% had increased mortality (hazard ratio [HR], 1.58; P<0.001), with similar risk increase in both symptomatic (HR, 1.56; P<0.001) and asymptomatic patients (HR, 1.58; P=0.006). Correcting for risk factors, LV mass index, aortic valve area, and stroke volume index, LVEF was independently predictive of mortality (HR, 0.88 per 10%; P<0.001). When this analysis was repeated in the subset of 1333 patients without history of coronary artery disease, LVEF remained associated with mortality (HR, 0.90 per 10%; P=0.009). Conclusions - LVEF is a powerful predictor of outcome in patients with severe aortic stenosis undergoing aortic valve replacement, independent of the presence of valve-related symptoms.

KW - aortic valve

KW - aortic valve stenosis

KW - cardiac surgical procedures

KW - echocardiography

KW - ventricular remodeling

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U2 - 10.1161/CIRCIMAGING.114.002917

DO - 10.1161/CIRCIMAGING.114.002917

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AN - SCOPUS:84937611070

VL - 8

JO - Circulation: Cardiovascular Imaging

JF - Circulation: Cardiovascular Imaging

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