Relation of preprocedural assessment of myocardial contractility reserve on outcomes of aortic stenosis patients with impaired left ventricular function undergoing transcatheter aortic valve implantation

Israel M Barbash, Sa'ar Minha, Itsik Ben-Dor, Danny Dvir, Marco A Magalhaes, Rebecca Torguson, Petros Okubagzi, Lowell F Satler, Augusto D Pichard, Ron Waksman
American Journal of Cardiology 2014 May 1, 113 (9): 1536-42
Transcatheter aortic valve implantation (TAVI) is associated with improved left ventricular (LV) function in patients with aortic stenosis (AS) and LV dysfunction; however, the outcome after TAVI of patients with low left ventricular ejection fraction (LVEF) is unclear. This study aimed to characterize the baseline, procedural, and long-term outcomes of patients with low LVEF undergoing TAVI and to assess the prognostic utility of pre-TAVI balloon aortic valvuloplasty (BAV) and dobutamine stress echocardiography (DSE) to predict TAVI benefits. Consecutive patients with symptomatic severe AS who underwent TAVI from 2007 to 2013 were analyzed. Two groups were compared: normal or near normal LV function (LVEF >45%) and LVEF ≤45% at baseline. In total, 371 patients were analyzed; 272 (73%) had preserved LVEF and 99 (27%) had low LVEF. Patients with low LVEF had higher Society of Thoracic Surgeons score and EuroSCORE. Short- and long-term mortality was similar between groups (1-year rate: 22.2% vs 22.4%, p = 0.79). Of the patients with low LVEF, 24% demonstrated improvement (≥10%) in LVEF at 30 days; patients with improvement had lower mortality at 1 year than those without (8% vs 27%, p = 0.06). Contractile reserve in DSE did not predict LVEF recovery in patients with low LVEF but did predict lower mortality. LVEF recovery after BAV predicted greater LVEF improvement after TAVI. In conclusion, patients with severe AS and impaired LV function benefit from TAVI and have comparable procedural outcomes compared with patients with preserved LVEF. Both DSE and BAV provide complementary data with regard to recovery of LVEF and mortality, both periprocedural and late after TAVI.

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