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Published on: May 21, 2017
Effect of left ventricular ejection fraction on postoperative outcome in patients with severe aortic stenosis
Jordi S Dahl1, Mackram F Eleid1, Hector I Michelena1
1From the Division of Cardiovascular Diseases (J.S.D., M.F.E., H.I.M., P.A.P.), Division of Biostatistics (C.G.S.), and Division of Cardiovascular Surgery (R.M.S., H.V.S.), Mayo Clinic, Rochester, MN.
Insights
Left ventricular ejection fraction (LVEF) predicts long-term outcomes in severe aortic stenosis patients undergoing aortic valve replacement. Higher LVEF, even above 50%, is associated with significantly lower mortality rates post-surgery.
Area of Science:
- Cardiology
- Cardiac Surgery
- Echocardiography
Background:
- Severe aortic stenosis guidelines recommend aortic valve replacement for asymptomatic patients with left ventricular ejection fraction (LVEF) <50%.
- The prognostic value of LVEF in both symptomatic and asymptomatic patients with severe aortic stenosis undergoing aortic valve replacement requires further investigation.
Purpose of the Study:
- To investigate the impact of preoperative left ventricular ejection fraction (LVEF) on long-term outcomes in patients with severe aortic stenosis undergoing aortic valve replacement.
- To determine if LVEF is an independent predictor of mortality in this patient population.
Main Methods:
- Retrospective analysis of 2017 patients with severe aortic stenosis who underwent surgical aortic valve replacement between 1995 and 2009.
- Patients were stratified into four groups based on preoperative LVEF (<50%, 50%-59%, 60%-69%, and ≥70%).
- Survival analysis was performed to assess the association between LVEF and long-term mortality, with adjustments for relevant risk factors.
Main Results:
- A significant inverse relationship was observed between LVEF and mortality; higher LVEF correlated with lower 5-year mortality rates.
- Patients with LVEF 50%-59% had increased mortality compared to those with LVEF ≥60% (HR 1.58, P<0.001), irrespective of symptoms.
- Preoperative LVEF was an independent predictor of mortality (HR 0.88 per 10% increase, P<0.001) even after adjusting for multiple risk factors and in patients without coronary artery disease.
Conclusions:
- Left ventricular ejection fraction (LVEF) is a potent predictor of long-term outcomes in patients with severe aortic stenosis undergoing aortic valve replacement.
- The prognostic significance of LVEF persists regardless of the presence or absence of symptoms related to aortic stenosis.
Background:
In asymptomatic patients with severe aortic stenosis, guidelines recommend left ventricular ejection fraction (LVEF) of <50% as the threshold for referral for aortic valve replacement. We investigated the importance of LVEF on long-term outcome after aortic valve replacement in symptomatic and asymptomatic patients with severe aortic stenosis.
Methods And Results:
We retrospectively identified 2017 patients with severe aortic stenosis (aortic valve area<1 cm(2), mean gradient≥40 mm Hg, or indexed aortic valve area<0.6 cm(2)/m(2)) who underwent surgical aortic valve replacement from January 1995 to June 2009. Patients were divided into 4 groups depending on preoperative LVEF (<50% in 300 [15%] patients, 50%-59% in 331 [17%], 60%-69% in 908 [45%], and ≥70% in 478 [24%]). During follow-up of 5.3±4.4 years, 1056 (52%) patients died. A decrease in mortality was observed with increasing LVEF, P<0.0001; 5-year mortality estimates (95% confidence interval) were 0.41 (0.35-0.47), LVEF<50%; 0.35 (0.29-0.41), LVEF 50% to 59%; 0.26 (0.23-0.29), LVEF 60% to 69%; and 0.22 (0.18-0.26), LVEF≥70%. Compared with patients with LVEF≥60%, patients with LVEF 50% to 59% had increased mortality (hazard ratio [HR], 1.58; P<0.001), with similar risk increase in both symptomatic (HR, 1.56; P<0.001) and asymptomatic patients (HR, 1.58; P=0.006). Correcting for risk factors, LV mass index, aortic valve area, and stroke volume index, LVEF was independently predictive of mortality (HR, 0.88 per 10%; P<0.001). When this analysis was repeated in the subset of 1333 patients without history of coronary artery disease, LVEF remained associated with mortality (HR, 0.90 per 10%; P=0.009).
Conclusions:
LVEF is a powerful predictor of outcome in patients with severe aortic stenosis undergoing aortic valve replacement, independent of the presence of valve-related symptoms.
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