Preoperative LVEF was independently predictive of mortality in patients with severe aortic stenosis undergoing aortic valve replacement (HR 0.88 per 10% increase; P<0.001).
Cohort (n=2,017)
Does preoperative LVEF predict long-term mortality in patients with severe aortic stenosis undergoing surgical aortic valve replacement?
In patients with severe aortic stenosis undergoing surgical aortic valve replacement, a preoperative LVEF of 50-59% is associated with significantly higher long-term mortality compared to an LVEF ≥60%, challenging the traditional guideline threshold of <50% for intervention.
Effect estimate: HR 0.88
p-value: p=<0.001
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 2 , mean gradient≥40 mm Hg, or indexed aortic valve area<0.6 cm 2 /m 2 ) 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.
Dahl et al. (2015) conducted a cohort in Severe aortic stenosis (n=2,017). Preoperative LVEF was evaluated on Mortality (HR 0.88, p=<0.001). Preoperative LVEF was independently predictive of mortality in patients with severe aortic stenosis undergoing aortic valve replacement (HR 0.88 per 10% increase; P<0.001).