Aortic valve replacement in patients with aortic stenosis and severe left ventricular dysfunction

Area of Science:

• Cardiology
• Cardiac Surgery
• Echocardiography

Background:

• Severe aortic stenosis (AS) with impaired left ventricular (LV) function portends a worse prognosis after aortic valve replacement (AVR).
• LV dysfunction in AS may be reversible if due to afterload mismatch, but not if caused by myocardial infarction (MI).

Purpose of the Study:

• To assess the impact of prior myocardial infarction (MI) on operative mortality in patients with severe aortic stenosis and severely reduced left ventricular ejection fraction undergoing aortic valve replacement (AVR).

Main Methods:

• Retrospective review of 55 patients with severe AS (valve area ≤0.75 cm2) and ejection fraction ≤30% who underwent AVR.
• Analysis of operative mortality and clinical follow-up data, specifically comparing outcomes between patients with and without a history of MI.

Main Results:

• Overall operative mortality was 18% (10 of 55 patients).
• Twenty patients (36%) had a prior MI, with a significantly higher mortality rate of 45% (9 of 20) compared to 3% (1 of 35) in those without prior MI (P≤0.001).
• Multivariate analysis identified prior MI as the only independent predictor of perioperative death (OR, 14.9; P=0.004).

Conclusions:

• Prior MI dramatically increases the risk of AVR in patients with severe AS and severely reduced LV systolic function.
• This finding necessitates careful consideration in the preoperative risk-benefit analysis for these high-risk patients.
• Operation may be precluded for some patients with a history of MI due to prohibitive risk.