CLINICAL STUDY: VALVE DISEASE
Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients
Risk stratification by low-dose dobutamine echocardiography
Jean-Luc Monin, MD*,
Mehran Monchi, MD ,
Virginie Gest, MD*,
Anne-Marie Duval-Moulin, MD*,
Jean-Luc Dubois-Rande, MD, PhD* and
Pascal Gueret, MD, FACC*
* Fédération de Cardiologie, Hôpital Henri Mondor, Créteil, France
University Hospital Sart Tilman, Liège, Belgium
Manuscript received November 12, 2000;
revised manuscript received March 1, 2001,
accepted March 22, 2001.
Reprint requests and correspondence: Dr. J. L. Monin, Fédération de Cardiologie, Hôpital Henri Mondor, 51 Avenue De Lattre de Tassigny, 94010 Créteil, France
jean-luc.monin{at}hmn.ap.hop.paris.fr
OBJECTIVES
We sought to assess risk stratification by using dobutamine stress echocardiography (DSE) in patients with aortic stenosis (AS) and severe left ventricular (LV) dysfunction.
BACKGROUND
Few data are available on risk stratification for valve replacement in patients with AS, LV dysfunction and low transvalvular gradients.
METHODS
Low-dose DSE was performed in 45 patients (16 women and 29 men; median [quartile range] age in years: 75 [69 to 79]; left ventricular ejection fraction: 0.29 [0.23 to 0.32]; aortic valve area [cm2]: 0.7 [0.5 to 0.8]; mean transaortic gradient [mm Hg]: 26 [21 to 33]). Patients were classified into two groups: group I (n = 32, LV contractile reserve on DSE) and group II (n = 13, no contractile reserve). Valve replacement was performed in 24 and 6 patients in groups I and II, respectively.
RESULTS
Perioperative mortality was 8% in group I and 50% in group II (p = 0.014). Survival at five years after the operation was 88% in group I. Compared with medical therapy, valve surgery was associated with better long-term survival in group I (hazard ratio for death [HR-D] 0.13, 95% confidence interval [CI] 0.002 to 0.49) and reduced survival in group II (HR-D 19.6, 95% CI 2.7 to 142). The effect of valve surgery on survival remained significant in both groups after adjustment for age, diabetes, respiratory disease and hypertension. Medical therapy had the same effect in both groups.
CONCLUSIONS
In patients with AS, LV dysfunction and low transvalvular gradients, contractile reserve on DSE is associated with a low operative risk and good long-term prognosis after valve surgery. In contrast, operative mortality remains high in the absence of contractile reserve.
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Abbreviations and Acronyms
| | AS | = aortic stenosis | | AVA | = aortic valve area | | CABG | = coronary artery bypass graft surgery | | CAD | = coronary artery disease | | DSE | = dobutamine stress echocardiography | | LV | = left ventricle or ventricular | | LVEF | = left ventricular ejection fraction | | LVOT | = left ventricular outflow tract | | MPG | = mean pressure gradient | | NYHA | = New York Heart Association | | SV | = stroke volume |
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