Affiliation:
1. From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, and Menzies Research Institute Tasmania, Hobart, Australia.
Abstract
Background—
The optimal management of low-gradient “severe” aortic stenosis (mean gradient <40 mm Hg, indexed aortic valve area ≤0.6 cm
2
/m
2
) with preserved left ventricular ejection fraction remains controversial because gradients may be similar after aortic valve replacement (AVR). We compared outcomes of low-gradient severe aortic stenosis with AVR or medical therapy.
Methods and Results—
Comprehensive echocardiographic measurements including hemodynamic calculations were completed in 260 prospectively identified patients with symptomatic low-gradient severe aortic stenosis. Patients were followed up for mortality over 28±24 months. AVR was performed in 123 patients (47%). Compared with AVR patients, medically treated patients had a higher prevalence of diabetes mellitus (25% versus 41%,
P
=0.009), lower stroke volume index (36.4±8.4 versus 34.4±8.7 mL/m
2
,
P
=0.02), higher pulmonary artery pressure (38±11 versus 48±21 mm Hg,
P
=0.001), and higher creatinine level (1.1±0.4 versus 1.22±0.5 mg/dL,
P
=0.02). These and other clinically relevant variables were entered into a propensity model that reflected likelihood of referral to AVR. This score and other variables were entered into a Cox model to explore the independent effect of AVR on outcome. During follow-up, 105 patients died (40%): 32 (30%) in the AVR group and 73 (70%) in the medical treatment group. AVR (hazard ratio, 0.54; 95% confidence interval, 0.32–0.94;
P
<0.001) was independently associated with outcome and remained a strong predictor of survival after adjustment for propensity score. Medical therapy was associated with 2-fold greater all-cause mortality than AVR. The protective effect of AVR was similar in 125 patients with normal flow (stroke volume index >35 mL/m
2
;
P
=0.22).
Conclusions—
AVR is associated with better survival than medical therapy in patients with symptomatic low-gradient severe AS and preserved left ventricular ejection fraction.
Publisher
Ovid Technologies (Wolters Kluwer Health)
Subject
Physiology (medical),Cardiology and Cardiovascular Medicine
Reference21 articles.
1. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease
2. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.;American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons;Circulation,2006
3. Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice
4. Paradoxical Low-Flow, Low-Gradient Severe Aortic Stenosis Despite Preserved Ejection Fraction Is Associated With Higher Afterload and Reduced Survival
5. Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis
Cited by
115 articles.
订阅此论文施引文献
订阅此论文施引文献，注册后可以免费订阅5篇论文的施引文献，订阅后可以查看论文全部施引文献