Outcomes From Transcatheter Aortic Valve Replacement in Patients With Low-Flow, Low-Gradient Aortic Stenosis and Left Ventricular Ejection Fraction Less Than 30%
Authors: Frédéric Maes, Stamatios Lerakis, Henrique Barbosa Ribeiro, Martine Gilard, João L. Cavalcante, Raj Makkar, Howard C. Herrmann, Stephan Windecker, Maurice Enriquez-Sarano, Asim N. Cheema, Luis Nombela-Franco, Ignacio Amat-Santos, Antonio J. Muñoz-García, Bruno Garcia del Blanco, Alan Zajarias, John C. Lisko, Salim Hayek, Vasilis Babaliaros, Florent Le Ven, Thomas G. Gleason, Tarun Chakravarty, Wilson Szeto, Marie-Annick Clavel, Alberto de Agustin, Vicenç Serra, John T. Schindler, Abdellaziz Dahou, Mohammed Salah-Annabi, Emilie Pelletier-Beaumont, Melanie Côté, Rishi Puri, Philippe Pibarot, Josep Rodés-Cabau
Journal: JAMA Cardiology (2018)

<h3>Importance</h3> In low-flow, low-gradient aortic stenosis (LFLG AS), the severity of left ventricular dysfunction remains a key factor in the evaluation of aortic valve replacement. <h3>Objective</h3> To evaluate the clinical outcomes and changes in left ventricular ejection fraction (LVEF) after transcatheter aortic valve replacement (TAVR) in patients with LFLG AS and severe left ventricular dysfunction. <h3>Design, Setting, and Participants</h3> This multicenter registry is a substudy of the True or Pseudo-Severe Aortic Stenosis–TAVI registry that included patients with classic LFLG AS, defined as a mean transvalvular gradient less than 35 mm Hg, an effective orifice area less than 1.0 cm<sup>2</sup>, and an LVEF of 40% or less. Patients were divided in groups with very low (&lt;30%) LVEF and low (30%-40%) LVEF. Dobutamine stress echocardiography (DSE) was performed before TAVR in a subset with very low LVEF, and presence of contractile reserve was defined as an increase of 20% or more in stroke volume. Clinical outcomes were assessed at 1 and 12 months and yearly thereafter, and echocardiography was performed at 1-year follow-up. Retrospective data were collected from 2007 to 2013 and prospective data from January 2013 to March 2018. Data were analyzed from March to October 2018. <h3>Exposures</h3> Transcatheter aortic valve replacement in patients with LFLG AS. <h3>Main Outcomes and Measures</h3> Changes in LVEF over time; periprocedural and late mortality. <h3>Results</h3> A total of 293 patients were included, including 128 (43.7%) with very low LVEF and 165 with low LVEF (56.3%). Their mean (SD) age was 80 (7) years, and most (214 [73.0%]) were men. The mean (SD) LVEF in the very low LVEF group was 22% (5%), compared with 37% (7%) in the low LVEF group (<i>P</i> &lt; .001). There were no differences between groups in rates of periprocedural mortality and late mortality (median [interquartile range], 23 [6-38] months). Patients with very low LVEF displayed a greater increase in LVEF at the 1-year follow-up examination (mean absolute increase, 11.9% [95% CI, 8.8%-15.1%]), than the low LVEF group (3.6% [95% CI, 1.1%-6.1%];<i>P</i> &lt; .001). In 92 patients with very low LVEF who had preprocedural DSE, results showed a lack of contractile reserve in 45 (49%), but this had no effect on clinical outcomes or changes in LVEF over time. <h3>Conclusions and Relevance</h3> In patients with LFLG AS and severe left ventricular dysfunction, TAVR was associated with similar clinical outcomes as in counterparts with milder left ventricular dysfunction. The TAVR procedure was associated with a significant increase in LVEF, irrespective of contractile reserve. These results support TAVR for LFLG AS, irrespective of the severity of left ventricular dysfunction and DSE results.