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Canadian Journal of Cardiology

Impact of Left-Ventricular Dysfunction in Patients With High- and Low- Gradient Severe Aortic Stenosis Following Transcatheter Aortic Valve Replacement

Published:November 04, 2020DOI:https://doi.org/10.1016/j.cjca.2020.10.014

      Abstract

      Background

      Outcomes of transcatheter aortic valve replacement (TAVR) in patients with high-gradient (HG) severe aortic stenosis (AS) and reduced left-ventricular (LV) ejection fraction (EF) are unknown.

      Methods

      Patients undergoing TAVR for native severe AS between 2009 and 2018 were retrospectively included and classified into 3 groups: HG (≥ 40 mm Hg) and preserved EF (≥ 50%), HG low EF (< 50%), and low gradient (LG < 40 mm Hg) low EF. The primary endpoint was a composite of cardiovascular mortality and readmission for heart failure at 1 year after TAVR.

      Results

      Of the 526 patients included, 323 (61%) had HG preserved EF, 69 (13%) had HG low EF, and 134 (26%) had LG low EF. HG low EF group had higher prevalence of atrial fibrillation and heart failure and higher Society of Thoracic Surgeons score compared with the HG preserved EF group. Patients in the LG low EF group were older and had higher prevalence of coronary artery disease compared with those in the HG groups. All-cause mortality at 30 days (4.0%) was similar across the 3 groups. After adjustment, the risk of primary endpoint was similar in the HG low-EF vs preserved EF groups. Conversely, the risk of primary endpoint was higher in the LG low EF group vs the HG preserved EF group (hazard ratio [HR], 2.24; 95% confidence interval [CI],1.36-3.70; P = 0.002) and vs HG low EF group (HR, 3.50; 95% CI, 1.55-7.90; P = 0.003), whereas the risk of all-cause mortality was similar across the 3 groups.

      Conclusions

      The outcome of patients with HG low EF severe AS following TAVR is as good as that of patients with HG preserved EF.

      Résumé

      Contexte

      Les résultats d’une implantation valvulaire aortique par cathéter (IVAC) chez les patients présentant une sténose aortique (SA) sévère à gradient élevé (GE) et une fraction d’éjection (FE) ventriculaire gauche réduite sont mal connus.

      Méthodologie

      Les patients ayant subi une IVAC en raison d’une SA sévère entre 2009 et 2018 ont été inclus rétrospectivement dans notre étude et classés en trois groupes : GE (≥ 40 mmHg) et FE préservée (≥ 50 %), GE et FE réduite (< 50 %) et gradient bas (GB < 40 mmHg) et FE réduite. Le critère d’évaluation principal comprenait la mortalité cardiovasculaire et la réadmission pour insuffisance cardiaque dans l’année suivant l’IVAC.

      Résultats

      Sur les 526 patients inclus dans l’étude, 323 (61 %) présentaient un GE et une FE préservée, 69 (13 %) présentaient un GE et une FE réduite et 134 (26 %) présentaient un GB et une FE réduite. Dans le groupe GE-FE réduite, les antécédents de fibrillation auriculaire et d’insuffisance cardiaque étaient plus nombreux et les patients avaient un score STS (Society of Thoracic Surgeons) plus élevé que dans le groupe GE-FE préservée. Les patients du groupe GB-FE réduite étaient plus âgés et étaient plus nombreux à présenter une coronaropathie que ceux des groupes GE. Le taux de mortalité toutes causes confondues à 30 jours (4,0 %) était comparable dans les 3 groupes. Après ajustement, le risque de survenue d’un des événements composant le critère d’évaluation principal était comparable dans le groupe GE-FE réduite et dans le groupe GE-FE préservée. En revanche, le risque de survenue d’un des événements du critère d’évaluation principal était plus élevé dans le groupe GB-FE réduite que dans le groupe GE-FE préservée (rapport des risques instantanés [RRI] : 2,24; intervalle de confiance [IC] à 95 % : de 1,36 à 3,70; p = 0,002) et que dans le groupe GE-FE réduite (RRI : 3,50; IC à 95 % : de 1,55 à 7,90; p = 0,003), tandis que le risque de mortalité toutes causes confondues était comparable dans les 3 groupes.

      Conclusions

      Les résultats de l’IVAC obtenus chez les patients présentant une SA sévèr eavec GE et FE réduite sont aussi bons que chez les patients présentant une SA sévèr eavec GE et FE préservée.
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