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J Am Coll Cardiol, 2002; 39:1356-1363
© 2002 by the American College of Cardiology Foundation
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CLINICAL STUDY: VALVE DISEASE

Survival after aortic valve replacement forsevere aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction

Jeremy J. Pereira, MB, BS*, Michael S. Lauer, MD, FACC*, Mohammad Bashir, MB, BS*, Imran Afridi, MD, FACC*, Eugene H. Blackstone, MD, FACC{dagger}, William J. Stewart, MD, FACC*, Patrick M. McCarthy, MD{dagger}{ddagger}, James D. Thomas, MD, FACC* and Craig R. Asher, MD, FACC*,*

* Departments of Cardiology, Cleveland Clinic Foundation, Cleveland, OhioUSA
{dagger} Cardiothoracic Surgery, Cleveland Clinic Foundation, Cleveland, OhioUSA
{ddagger} Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, OhioUSA

Manuscript received August 28, 2000; revised manuscript received November 28, 2001, accepted January 30, 2002.

* Reprint requests and correspondence: Dr. Craig R. Asher, The Cleveland Clinic Foundation, Desk F-15, 9500 Euclid Avenue, Cleveland, Ohio 44195 USA
asherc{at}ccf.org

OBJECTIVES: We sought to assess whether aortic valve replacement (AVR) among patients with severe aortic stenosis (AS), severe left ventricular (LV) dysfunction and a low transvalvular gradient (TVG) is associated with improved survival.

BACKGROUND: The optimal management of patients with severe AS with severe LV dysfunction and a low TVG remains controversial.

METHODS: Between 1990 and 1998, we evaluated 68 patients who underwent AVR at our institution (AVR group) and 89 patients who did not undergo AVR (control group), with an aortic valve area ≤0.75 cm2, LV ejection fraction ≤35% and mean gradient ≤30 mm Hg. Using propensity analysis, survival was compared between a cohort of 39 patients in the AVR group and 56 patients in the control group.

RESULTS: Despite well-matched baseline characteristics among propensity-matched patients, the one- and four-year survival rates were markedly improved in patients in the AVR group (82% and 78%), as compared with patients in the control group (41% and 15%; p < 0.0001). By multivariable analysis, the main predictor of improved survival was AVR (adjusted risk ratio 0.19, 95% confidence interval 0.09 to 0.39; p < 0.0001). The only other predictors of mortality were age and the serum creatinine level.

CONCLUSIONS: Among select patients with severe AS, severe LV dysfunction and a low TVG, AVR was associated with significantly improved survival.

Abbreviations and Acronyms
  AS
  aortic stenosis
  AVR
  aortic valve replacement
  AVA
  aortic valve area
  CABG
  coronary artery bypass graft surgery
  CAD
  coronary artery disease
  CCS
  Canadian Cardiovascular Society
  CI
  confidence interval
  LV
  left ventricular
  LVEF
  left ventricular ejection fraction
  NYHA
  New York Heart Association
  RR
  risk ratio
  TVG
  transvalvular gradient




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