Impact of ejection fraction and aortic valve gradient on outcomes of transcatheter aortic valve replacement

Suzanne J. Baron, Suzanne V. Arnold, Howard C. Herrmann, David Holmes, Wilson Y. Szeto, Keith B. Allen, Adnan K. Chhatriwalla, Sreekaanth Vemulapali, Sean O'Brien, Dadi Dai, David J. Cohen

Research output: Contribution to journalArticle

40 Citations (Scopus)

Abstract

Background In patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), studies have suggested that reduced left ventricular (LV) ejection fraction (LVEF) and low aortic valve gradient (AVG) are associated with worse long-term outcomes. Because these conditions commonly coexist, the extent to which they are independently associated with outcomes after TAVR is unknown. Objectives The purpose of this study was to evaluate the impact of LVEF and AVG on clinical outcomes after TAVR and to determine whether the effect of AVG on outcomes is modified by LVEF. Methods Using data from 11,292 patients who underwent TAVR as part of the Transcatheter Valve Therapies Registry, we examined rates of 1-year mortality and recurrent heart failure in patients with varying levels of LV dysfunction (LVEF <30% vs. 30% to 50% vs. >50%) and AVG (<40 mm Hg vs. ≥40 mm Hg). Multivariable models were used to estimate the independent effect of AVG and LVEF on outcomes. Results During the first year of follow-up after TAVR, patients with LV dysfunction and low AVG had higher rates of death and recurrent heart failure. After adjustment for other clinical factors, only low AVG was associated with higher mortality (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32; p < 0.001) and higher rates of heart failure (hazard ratio: 1.52; 95% confidence interval: 1.36 to 1.69; p <0.001), whereas the effect of LVEF was no longer significant. There was no evidence of effect modification between AVG and LVEF with respect to either endpoint. Conclusions In this series of real-world patients undergoing TAVR, low AVG, but not LV dysfunction, was associated with higher rates of mortality and recurrent heart failure. Although these findings suggest that AVG should be considered when evaluating the risks and benefits of TAVR for individual patients, neither severe LV dysfunction nor low AVG alone or in combination provide sufficient prognostic discrimination to preclude treatment with TAVR.

Original languageEnglish (US)
Pages (from-to)2349-2358
Number of pages10
JournalJournal of the American College of Cardiology
Volume67
Issue number20
DOIs
StatePublished - May 24 2016

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Aortic Valve
Left Ventricular Dysfunction
Heart Failure
Mortality
Transcatheter Aortic Valve Replacement
Confidence Intervals
Aortic Valve Stenosis
Stroke Volume
Registries

Keywords

  • AV gradient
  • left ventricular dysfunction
  • LVEF
  • stroke
  • surgical aortic valve replacement
  • TAVR

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Impact of ejection fraction and aortic valve gradient on outcomes of transcatheter aortic valve replacement. / Baron, Suzanne J.; Arnold, Suzanne V.; Herrmann, Howard C.; Holmes, David; Szeto, Wilson Y.; Allen, Keith B.; Chhatriwalla, Adnan K.; Vemulapali, Sreekaanth; O'Brien, Sean; Dai, Dadi; Cohen, David J.

In: Journal of the American College of Cardiology, Vol. 67, No. 20, 24.05.2016, p. 2349-2358.

Research output: Contribution to journalArticle

Baron, SJ, Arnold, SV, Herrmann, HC, Holmes, D, Szeto, WY, Allen, KB, Chhatriwalla, AK, Vemulapali, S, O'Brien, S, Dai, D & Cohen, DJ 2016, 'Impact of ejection fraction and aortic valve gradient on outcomes of transcatheter aortic valve replacement', Journal of the American College of Cardiology, vol. 67, no. 20, pp. 2349-2358. https://doi.org/10.1016/j.jacc.2016.03.514
Baron, Suzanne J. ; Arnold, Suzanne V. ; Herrmann, Howard C. ; Holmes, David ; Szeto, Wilson Y. ; Allen, Keith B. ; Chhatriwalla, Adnan K. ; Vemulapali, Sreekaanth ; O'Brien, Sean ; Dai, Dadi ; Cohen, David J. / Impact of ejection fraction and aortic valve gradient on outcomes of transcatheter aortic valve replacement. In: Journal of the American College of Cardiology. 2016 ; Vol. 67, No. 20. pp. 2349-2358.
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abstract = "Background In patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), studies have suggested that reduced left ventricular (LV) ejection fraction (LVEF) and low aortic valve gradient (AVG) are associated with worse long-term outcomes. Because these conditions commonly coexist, the extent to which they are independently associated with outcomes after TAVR is unknown. Objectives The purpose of this study was to evaluate the impact of LVEF and AVG on clinical outcomes after TAVR and to determine whether the effect of AVG on outcomes is modified by LVEF. Methods Using data from 11,292 patients who underwent TAVR as part of the Transcatheter Valve Therapies Registry, we examined rates of 1-year mortality and recurrent heart failure in patients with varying levels of LV dysfunction (LVEF <30{\%} vs. 30{\%} to 50{\%} vs. >50{\%}) and AVG (<40 mm Hg vs. ≥40 mm Hg). Multivariable models were used to estimate the independent effect of AVG and LVEF on outcomes. Results During the first year of follow-up after TAVR, patients with LV dysfunction and low AVG had higher rates of death and recurrent heart failure. After adjustment for other clinical factors, only low AVG was associated with higher mortality (hazard ratio: 1.21; 95{\%} confidence interval: 1.11 to 1.32; p < 0.001) and higher rates of heart failure (hazard ratio: 1.52; 95{\%} confidence interval: 1.36 to 1.69; p <0.001), whereas the effect of LVEF was no longer significant. There was no evidence of effect modification between AVG and LVEF with respect to either endpoint. Conclusions In this series of real-world patients undergoing TAVR, low AVG, but not LV dysfunction, was associated with higher rates of mortality and recurrent heart failure. Although these findings suggest that AVG should be considered when evaluating the risks and benefits of TAVR for individual patients, neither severe LV dysfunction nor low AVG alone or in combination provide sufficient prognostic discrimination to preclude treatment with TAVR.",
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AU - Baron, Suzanne J.

AU - Arnold, Suzanne V.

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AU - Holmes, David

AU - Szeto, Wilson Y.

AU - Allen, Keith B.

AU - Chhatriwalla, Adnan K.

AU - Vemulapali, Sreekaanth

AU - O'Brien, Sean

AU - Dai, Dadi

AU - Cohen, David J.

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N2 - Background In patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), studies have suggested that reduced left ventricular (LV) ejection fraction (LVEF) and low aortic valve gradient (AVG) are associated with worse long-term outcomes. Because these conditions commonly coexist, the extent to which they are independently associated with outcomes after TAVR is unknown. Objectives The purpose of this study was to evaluate the impact of LVEF and AVG on clinical outcomes after TAVR and to determine whether the effect of AVG on outcomes is modified by LVEF. Methods Using data from 11,292 patients who underwent TAVR as part of the Transcatheter Valve Therapies Registry, we examined rates of 1-year mortality and recurrent heart failure in patients with varying levels of LV dysfunction (LVEF <30% vs. 30% to 50% vs. >50%) and AVG (<40 mm Hg vs. ≥40 mm Hg). Multivariable models were used to estimate the independent effect of AVG and LVEF on outcomes. Results During the first year of follow-up after TAVR, patients with LV dysfunction and low AVG had higher rates of death and recurrent heart failure. After adjustment for other clinical factors, only low AVG was associated with higher mortality (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32; p < 0.001) and higher rates of heart failure (hazard ratio: 1.52; 95% confidence interval: 1.36 to 1.69; p <0.001), whereas the effect of LVEF was no longer significant. There was no evidence of effect modification between AVG and LVEF with respect to either endpoint. Conclusions In this series of real-world patients undergoing TAVR, low AVG, but not LV dysfunction, was associated with higher rates of mortality and recurrent heart failure. Although these findings suggest that AVG should be considered when evaluating the risks and benefits of TAVR for individual patients, neither severe LV dysfunction nor low AVG alone or in combination provide sufficient prognostic discrimination to preclude treatment with TAVR.

AB - Background In patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), studies have suggested that reduced left ventricular (LV) ejection fraction (LVEF) and low aortic valve gradient (AVG) are associated with worse long-term outcomes. Because these conditions commonly coexist, the extent to which they are independently associated with outcomes after TAVR is unknown. Objectives The purpose of this study was to evaluate the impact of LVEF and AVG on clinical outcomes after TAVR and to determine whether the effect of AVG on outcomes is modified by LVEF. Methods Using data from 11,292 patients who underwent TAVR as part of the Transcatheter Valve Therapies Registry, we examined rates of 1-year mortality and recurrent heart failure in patients with varying levels of LV dysfunction (LVEF <30% vs. 30% to 50% vs. >50%) and AVG (<40 mm Hg vs. ≥40 mm Hg). Multivariable models were used to estimate the independent effect of AVG and LVEF on outcomes. Results During the first year of follow-up after TAVR, patients with LV dysfunction and low AVG had higher rates of death and recurrent heart failure. After adjustment for other clinical factors, only low AVG was associated with higher mortality (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32; p < 0.001) and higher rates of heart failure (hazard ratio: 1.52; 95% confidence interval: 1.36 to 1.69; p <0.001), whereas the effect of LVEF was no longer significant. There was no evidence of effect modification between AVG and LVEF with respect to either endpoint. Conclusions In this series of real-world patients undergoing TAVR, low AVG, but not LV dysfunction, was associated with higher rates of mortality and recurrent heart failure. Although these findings suggest that AVG should be considered when evaluating the risks and benefits of TAVR for individual patients, neither severe LV dysfunction nor low AVG alone or in combination provide sufficient prognostic discrimination to preclude treatment with TAVR.

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KW - surgical aortic valve replacement

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