Outcomes After Aortic Valve Replacement for Aortic Stenosis Based on LVEF and Flow | Journal Scan

Study Questions:

Are there differences in outcomes after aortic valve replacement (AVR) among patients with aortic stenosis (AS) based on preoperative low ejection fraction (EF), low-flow with normal EF, or normal flow with normal EF?


A group of 1,154 patients with severe AS who underwent AVR with or without coronary artery bypass grafting was examined. Among these, 206 (18%) had a low left ventricular EF (LVEF) (defined as EF <50%), 319 (28%) had paradoxical low-flow but normal EF (defined as EF ≥50% and stroke volume indexed to body surface area [SVi] ≤35 ml/m2), and 629 (54%) had normal flow (defined as EF ≥50% and SVi >35 ml/m2). Perioperative (30-day) and 5-year mortality were assessed.


Aortic valve area was lower in low-flow groups (low EF 0.71 ± 0.20, paradoxical normal EF 0.65 ± 0.23 vs. normal flow, 0.77 ± 0.18 cm2; p < 0.001). In the low EF group, patients with low EF had a higher burden of coronary artery disease based on Duke myocardial jeopardy score, with a higher estimated surgical risk based on the Parsonnet score. Thirty-day mortality was higher (p < 0.001) in low EF and paradoxical normal EF groups compared to the normal flow group (6.3 and 6.3 vs. 1.8%, respectively). Independent predictors of operative mortality were SVi (odds ratio [OR], 1.18; p < 0.05) and the paradoxical low-flow group (OR, 2.97; p = 0.004). At 5 years after AVR, overall survival was 72 ± 4% in the low EF group, 81 ± 2% in paradoxical low-flow group, and 85 ± 2% in the normal flow group (p < 0.0001).


Patients with low EF and patients with paradoxical low-flow but normal EF have a higher 30-day mortality after AVR for AS. Although higher mortality among patients with low EF was related to higher operative risk scores, paradoxical low-flow remained a predictor of increased operative mortality independent of operative risk score. Mortality after 30 days remained higher among patients with low EF than among patients with normal flow or paradoxical low-flow AS. The authors advocate including stroke volume index in the assessment of perioperative risk among patients undergoing AVR for AS.


Patients with low-flow severe AS and ‘paradoxical’ normal LVEF appear to be at increased risk after AVR. Previously published data suggest that they also are at high risk without AVR. Among patients with AS and high predicted operative risk for AVR, assessment of stroke volume index could help further triage risk, and potentially help with transcatheter versus surgical AVR decision making.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease

Keywords: Aortic Valve, Aortic Valve Insufficiency, Transcatheter Aortic Valve Replacement, Body Surface Area, Coronary Artery Bypass, Coronary Artery Disease, Stroke Volume, Mortality, Risk

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