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Transcatheter aortic valve implantation in low ejection fraction/low transvalvular gradient patients: the rule of 40
Federico Conrotto1, Fabrizio D'Ascenzo, Pieter Stella
1aDivision of Cardiology, Città Della Salute e della Scienza Hospital, Turin, Italy bDepartment of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands cDivision of Cardiology, Istituto Clinico Humanitas dDepartment of Cardiology, Clinical Institute S. Ambrogio, Milan eDepartment of Cardiac, Thoracic and Vascular Sciences, Division of Cardiology, University of Padova, Padova fDivision of Cardiology, Policlinico Sant'Orsola-Malpighi, Bologna gDivision of Cardiac Surgery, Città Della Salute e della Scienza Hospital, University of Turin, Turin, Italy.
Insights
Patients undergoing transcatheter aortic valve implantation (TAVI) with both low left ventricular ejection fraction (LVEF) and low mean transaortic gradient (MTG) face higher mortality. Having at least one normal parameter predicts a good prognosis after TAVI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Predictors of outcomes after transcatheter aortic valve implantation (TAVI) are established, yet the roles of left ventricular ejection fraction (LVEF) and mean transaortic gradient (MTG) remain debated.
- This multicenter study investigates the prognostic significance of reduced LVEF and MTG in TAVI patients.
Purpose of the Study:
- To clarify the prognostic value of low LVEF and low MTG following TAVI.
- To identify patient subgroups at higher risk of mortality post-TAVI.
Main Methods:
- A cohort of 764 patients undergoing TAVI for severe symptomatic aortic valve stenosis between 2007 and 2012 was analyzed.
- Patients were stratified into four groups based on LVEF (≤40% vs. >40%) and MTG (<40 mmHg vs. ≥40 mmHg).
Main Results:
- Two-year mortality was significantly higher in patients with both low LVEF and low MTG (51.3%) compared to other groups (22.4%-25.5%).
- Multivariate analysis identified the combination of low LVEF and low MTG as the strongest predictor of mid-term mortality (HR 2.4; P=0.001).
Conclusions:
- A normal LVEF or MTG (above 40) predicts a favorable mid-term prognosis after TAVI.
- Patients with concurrent left ventricular dysfunction and a low mean aortic pressure gradient exhibit a high risk of all-cause mortality post-TAVI.
Background:
Several factors have been identified as predictors of events after transcatheter aortic valve implantation (TAVI) but the impact of left ventricular ejection fraction (LVEF) and mean transaortic gradient (MTG) is controversial. This multicenter study aimed to clarify the prognostic role of low LVEF and low MTG after TAVI.
Methods:
From 2007 to 2012, 764 consecutive patients with severe symptomatic aortic valve stenosis underwent TAVI at participating hospitals. Patients were divided according to LVEF and MTG into four groups.
Results:
Sixty-four patients had LVEF 40% or less and MTG less than 40 mmHg, 76 had LVEF 40% or less and MTG at least 40 mmHg, 163 had LVEF more than 40% and MTG less than 40 mmHg, 461 had LVEF more than 40% and MTG at least 40 mmHg. Two-year mortality was significantly higher in patients with low LVEF and low MTG, whereas it was similar in patients with low LVEF and high MTG, high LVEF and low MTG, and high LVEF and high MTG (51.3 vs. 22.4 vs. 23.3. vs. 25.5%, respectively; P = 0.001). These results were confirmed by multivariate analysis, as the combination of low LVEF and low MTG (both less than 40) was identified as the stronger mid-term mortality predictor (hazard ratio 2.4, confidence interval 95% 1.4-3.9; P = 0.001).
Conclusion:
At least one parameter between LVEF or MTG over 40 predicts a good prognosis for TAVI patients at mid-term follow-up, whereas those with both left ventricular dysfunction and low mean aortic pressure gradient are at high risk of all-cause death after TAVI.
