Asymptomatic Left Ventricular Systolic Dysfunction in Patients With Severe Aortic Stenosis: Characteristics and Outcomes
What are the prevalence, characteristics, and outcomes of asymptomatic left ventricular (LV) systolic dysfunction in patients with severe aortic stenosis (AS)?
A single-center retrospective study was performed at Mayo Clinic (Rochester, MN) that included adult patients ≥40 years of age with severe valvular AS (peak velocity ≥4 m/s, mean gradient >40 mm Hg, aortic valve area [AVA] <1 cm2, or AVA index <0.6 cm2/m2) from 1984 to 2010. Patients with prior cardiac surgery, severe coronary artery disease, or greater than moderate aortic regurgitation were excluded. Following identification of asymptomatic patients with severe AS and LV ejection fraction (EF) <50%, a 3:1 age/gender/date matched–control group of asymptomatic patients with severe AS meeting the same criteria except having LVEF ≥50% was performed.
Of 9,940 patients with severe AS, LV dysfunction was present among 1,960 (20%) patients at presentation, but only 43 (0.4%) patients had asymptomatic LV dysfunction. Age was 73 ± 14 years and 70% were male. Hypertension (78%) and LV hypertrophy (LV mass index 143 ± 36 g/m2) were characteristic. Of these patients, 53% developed symptoms at 21 ± 19 months after diagnosis. During 7.5 ± 6.7-year follow-up, 5-year mortality was 48%. After multivariable adjustment, there was no survival advantage associated with aortic valve replacement (AVR) in asymptomatic, severe AS with LV dysfunction (p = 0.51).
The authors concluded that in severe AS, the prevalence of asymptomatic LV systolic dysfunction is 0.4%. They further concluded that, despite absence of symptoms, patients with severe AS and LVEF <50% have a poor prognosis, with or without AVR.
Current and recent American College of Cardiology/American Heart Association and European Society of Cardiology guidelines include LV systolic dysfunction (EF <50%) as a Class I indication for AVR. This observational study confirms that, despite an absence of symptoms, the prognosis of patients with severe AS and LV systolic dysfunction is poor. Only 25 of 43 patients underwent AVR, and AVR was performed within 3 months of diagnosis in only seven patients. Without randomization to AVR or rationalization as to why patients with a widely accepted indication for AVR did not undergo intervention, caution is advised before concluding that AVR does not affect prognosis.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Heart Failure, Interventions and Coronary Artery Disease, Hypertension
Keywords: Hypertrophy, Left Ventricular, Heart Valve Prosthesis, Coronary Artery Disease, Follow-Up Studies, Dextromethorphan, Prevalence, Prognosis, Cardiomyopathies, Stroke Volume, Cardiac Surgical Procedures, Ventricular Dysfunction, Left, Hypertension, United States
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