Reduced Left Ventricular Ejection Fraction in Patients With Aortic Stenosis

Background: Left ventricular ejection fraction (LVEF) is reduced in a subset of patients with severe aortic stenosis (AS). Objectives: The authors sought to determine the temporal course of reduced LVEF, its predictors, and its impact on prognosis in severe AS. Methods: Serial echocardiograms of 928 consecutive patients with first-time diagnosis of severe AS (aortic valve area [AVA] ≤1 cm²) who had at least 1 echocardiogram before the diagnosis were evaluated. A total of 3,684 echocardiograms (median 3 studies per patient) within the preceding 10 years were analyzed. Results: At the initial diagnosis, 196 (21%) patients had an LVEF <50% (35.1 ± 9.7%) and 732 (79%) had an LVEF ≥50% (64.2 ± 6.1%). LVEF deterioration had begun before AS became severe for those with an LVEF <50% and accelerated after AVA reached 1.2 cm², whereas mean LVEF remained >60% in patients with LVEF ≥50% at initial diagnosis. The strongest predictor for LVEF deterioration was LVEF <60% at 3 years before AS became severe (odds ratio: 0.86; 95% confidence interval: 0.83 to 0.89; p < 0.001). During the median follow-up of 3.3 years, mortality was significantly worse, not only for patients with an LVEF <50%, but for patients with an LVEF of 50% ≤ LVEF <60% compared with patients with an LVEF ≥60% even after aortic valve replacement (p < 0.001). Conclusions: In patients with severe AS and reduced LVEF, a decline in LVEF began before AS became severe and accelerated after AVA reached 1.2 cm². LVEF <60% in the presence of moderate AS predicts further deterioration of LVEF and appears to represent abnormal LVEF in AS.