Surgical Aortic Valve Replacement in Severe Left Ventricular Dysfunction: Mortality, Echocardiographic, and Strain Outcomes

Abstract Background: Patients with severe left ventricular (LV) dysfunction (ejection fraction [EF] ≤35%) undergoing surgical aortic valve replacement (SAVR) are considered high-risk patients. This study evaluated contemporary outcomes in such patients undergoing SAVR for severe aortic stenosis (AS) or aortic regurgitation (AR) and identified clinical and echocardiographic predictors of mortality. Methods: This retrospective cohort study included 84 patients (>18 years) with EF ≤35% who underwent SAVR between 2015 and 2024. The cohort comprised 53 patients with AS and 31 with AR. Clinical, echocardiographic, and myocardial strain data were collected before and 6 months after SAVR. Mortality data were obtained from national registries, with follow-up through March 2025. Cox proportional hazards models were used to identify mortality predictors. Results: Median EF was 28% in AS and 31.1% in AR. Patients with AR were significantly younger than those with AS (44 vs. 63 years, p <0.001). In-hospital mortality for AS was 9.4%, increasing to 13.2% at 1 year and 43.4% at 55 months. Patients with AR showed no in-hospital deaths and 32.3% mortality at 55 months. Eight-year survival was 38.7% in patients with AS and 43.1% in patients with AR. In AS, hypertension (hazard ratio [HR] = 6.46, p = 0.012) and preoperative velocity time integral (HR = 0.97, p = 0.006) predicted mortality. In AR, only length of hospital stay (HR = 1.13, p = 0.017) was predictive. Conclusion: SAVR in severe LV dysfunction offers favorable medium-term survival, with clinical factors guiding prognosis. Trial Registration: Institut Jantung Negara Ethics Committee (IJNREC/779/2025).