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FOCUS ISSUE: VALVULAR HEART DISEASE: CLINICAL RESEARCH

Outcome After Aortic Valve Replacement for Low-Flow/Low-Gradient Aortic Stenosis Without Contractile Reserve on Dobutamine Stress Echocardiography

Christophe Tribouilloy, MD, PhD^_*,_*, Franck Lévy, MD, Dan Rusinaru, MD, Pascal Guéret, MD, Hélène Petit-Eisenmann, MD, Serge Baleynaud, MD^||, Yannick Jobic, MD^¶, Catherine Adams, MD^#, Bernard Lelong, MD^_**, Agnès Pasquet, MD, Christophe Chauvel, MD, Damien Metz, MD, Jean-Paul Quéré, MD^_* and Jean-Luc Monin, MD, PhD

^_* Department of Cardiology, INSERM, ERI-12, Amiens and University Hospital Amiens, Amiens, France
Department of Cardiac Surgery, University Hospital Amiens, Amiens, France
Department of Cardiology, Henri Mondor Hospital, Créteil, France
Department of Cardiac Surgery, University Hospital, Strasbourg, France
^|| Department of Cardiology, General Hospital, Lorient, France
^¶ Department of Cardiology, University Hospital, Brest, France
^# Department of Cardiology, General Hospital, Argenteuil, France
^_** Department of Thoracic and Cardiovascular Surgery, University Hospital, Rennes, France
Department of Cardiology, Clinique Universitaire St. Luc, Brussels, Belgium
Department of Cardiology, Clinique Saint-Augustin, Bordeaux, France
Department of Cardiology, University Hospital, Reims, France

Manuscript received November 18, 2008; revised manuscript received February 23, 2009, accepted February 23, 2009.

^_* Reprint requests and correspondence: Dr. Christophe Tribouilloy, INSERM, ERI-12, Amiens and Amiens University Hospital, Department of Cardiology, Avenue René Laënnec, 80054 Amiens Cedex 1, France (Email: tribouilloy.christophe{at}chu-amiens.fr).

Objectives: This study investigated whether aortic valve replacement (AVR) is associated with improved survival in patients with severe low-flow/low-gradient aortic stenosis (LF/LGAS) without contractile reserve (CR) on dobutamine stress echocardiography (DSE).

Background: Patients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial.

Methods: Eighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area 1 cm², left ventricular ejection fraction 40%, mean pressure gradient [MPG] 40 mm Hg) without CR on DSE were enrolled. Absence of CR was defined as the absence of increase in stroke volume of 20% compared with the baseline value. Multivariable analysis and propensity scores were used to compare survival according to whether or not AVR was performed (n = 55).

Results: Five-year survival was higher in AVR patients compared with medically managed patients (54 ± 7% vs. 13 ± 7%, p = 0.001) despite a high operative mortality of 22% (n = 12). An AVR was independently associated with lower 5-year mortality (adjusted hazard ratio from 0.16 to 5.21 varying with time [95% confidence interval: 0.12–3.16 to 0.21–8.50], p = 0.00026). In 42 propensity-matched patients, 5-year survival was markedly improved by AVR (65 ± 11% vs. 11 ± 7%, p = 0.019). Associated bypass surgery (p = 0.007) and MPG 20 mm Hg (p = 0.035) were independently predictive of operative mortality. Late survival after AVR (excluding operative death) was 69 ± 8% at 5 years.

Conclusions: In patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.

Key Words: low gradient aortic stenosis • left ventricular dysfunction • dobutamine stress echocardiography • prognosis • surgery

Abbreviations and Acronyms   AS = aortic stenosis   AVR = aortic valve replacement   CABG = coronary artery bypass graft surgery   CAD = coronary artery disease   CR = contractile reserve   DSE = dobutamine stress echocardiography   EuroSCORE = European System for Cardiac Operative Risk Evaluation   LF/LGAS = low-flow/low-gradient aortic stenosis   LVEF = left ventricular ejection fraction   MPG = mean transaortic pressure gradient   NYHA = New York Heart Association