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LVEF and Mortality in Asymptomatic and Minimally Symptomatic AS
Study Questions:
Is there an association between left ventricular ejection fraction (LVEF) and mortality among asymptomatic or minimally symptomatic patients with severe aortic stenosis (AS) with preserved LVEF (≥50%)?
Methods:
A cohort of 1,678 patients with severe native valve AS (aortic valve area ≤1 cm2 or valve area index ≤0.6 cm2/m2), LVEF ≥50%, and no symptoms or minimal symptoms (atypical chest pain, or elderly patients with minimal dyspnea thought unrelated to AS) was identified from an electronic database at two French and one Belgian tertiary care center. The population was retrospectively divided into three groups based on LVEF (LVEF 50-54%, 55%-59%, and ≥60%). Median follow-up was 43.0 months (interquartile range, 22-80 months); overall survival was assessed among medically and surgically managed patients.
Results:
The 5-year survival rate was 72 ± 2% for patients with LVEF ≥60%, 74 ± 2% for patients with LVEF 55-59%, and 59 ± 4% for patients with LVEF 50-54% (p < 0.001). With initial medical or initial surgical management (surgery within 3 months after baseline echocardiography), patients with LVEF 50-54% had a significant excess mortality compared to patients with LVEF ≥60% (adjusted hazard ratio [HR], 2.44; 95% confidence interval [CI], 1.51-3.94; p < 0.001 and HR, 2.51; 95% CI, 1.58-4.00; p < 0.001, respectively), whereas patients with LVEF 55-59% had comparable prognosis to those with LVEF ≥60% (p = 0.53 and p = 0.36, respectively). In patients with LVEF 50-55%, initial conservative management was associated with increased mortality compared to initial surgical management, even after covariate adjustment (HR, 2.70; 95% CI, 1.98-3.67; p < 0.001).
Conclusions:
Among patients with severe AS, preserved LVEF, and no or minimal symptoms at the time of diagnosis, LVEF <55% is a marker of worse outcome with either medical or surgical management. The authors concluded that surgery for severe AS should be considered before the LVEF decreases to <55%.
Perspective:
Aortic valve replacement is indicated among patients with severe AS and either symptoms or LVEF <50%. However, truly asymptomatic LV systolic dysfunction in the setting of severe AS probably is relatively uncommon. This study suggests that an LVEF <55% might be a marker of worse prognosis among patients with severe AS, whether patients are initially managed medically or surgically. At a minimum, patients with severe AS and LVEF between 50% and 55% probably should undergo additional scrutiny to assure that they are truly asymptomatic; if additional studies confirm the findings of this study, the threshold for ‘normal’ LVEF among patients with severe AS potentially could be shifted upward to ≥55%.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Chest Pain, Dyspnea, Echocardiography, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Stroke Volume, Tertiary Care Centers, Transcatheter Aortic Valve Replacement
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