Abstract:
BACKGROUND:Patients with low-flow, low-gradient aortic stenosis have a poor prognosis with conservative therapy but a high operative mortality if treated surgically. Recently, we proposed a new index of aortic stenosis severity derived from dobutamine stress echocardiography, the projected aortic valve area at a normal transvalvular flow rate, as superior to other conventional indices to differentiate true-severe from pseudosevere aortic stenosis. The objective of this study was to identify the determinants of survival, functional status, and change in left ventricular ejection fraction during follow-up of patients with low-flow, low-gradient aortic stenosis. METHODS AND RESULTS:One hundred one patients with low-flow, low-gradient aortic stenosis (aortic valve area =1.2 cm(2), left ventricular ejection fraction =40%, and mean gradient =40 mm Hg) underwent dobutamine stress echocardiography and an assessment of functional capacity using the Duke Activity Status Index. A subset of 72 patients also underwent a 6-minute walk test. Overall survival was 70+/-5% at 1 year and 57+/-6% at 3 years. After adjusting for age, gender, and the type of treatment (aortic valve replacement versus no aortic valve replacement), significant predictors of mortality during follow-up were a Duke Activity Status Index =20 (P=0.0005) or 6-minute walk test distance =320 m (P<0.0001, in the subset of 72 patients), projected aortic valve area at a normal transvalvular flow rate =1.2 cm(2) (P=0.03), and peak dobutamine stress echocardiography left ventricular ejection fraction =35% (P=0.03). More severe stenosis, defined as projected aortic valve area =1.2 cm(2), was a predictor of mortality only in the no aortic valve replacement group. The Duke Activity Status Index, 6-minute walk test, and left ventricular ejection fraction improved significantly during follow-up in the aortic valve replacement group, but remained unchanged or decreased in the no aortic valve replacement group. CONCLUSIONS:In patients with low-flow, low-gradient aortic stenosis, the most significant risk factors for poor outcome were (1) impaired functional capacity as measured by Duke Activity Status Index or 6-minute walk test distance; (2) more severe valve stenosis as measured by projected aortic valve area at a normal transvalvular flow rate; and (3) reduced peak stress left ventricular ejection fraction, a composite measure accounting for both resting left ventricular function and contractile reserve.
journal_name
Circulationjournal_title
Circulationauthors
Clavel MA,Fuchs C,Burwash IG,Mundigler G,Dumesnil JG,Baumgartner H,Bergler-Klein J,Beanlands RS,Mathieu P,Magne J,Pibarot Pdoi
10.1161/CIRCULATIONAHA.107.757427subject
Has Abstractpub_date
2008-09-30 00:00:00pages
S234-42issue
14 Suppleissn
0009-7322issn
1524-4539pii
118/14_suppl_1/S234journal_volume
118pub_type
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