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Relationship Between Left Ventricular Ejection Fraction and Mortality in Asymptomatic and Minimally Symptomatic

Yohann Bohbot¹, Christophe de Meester de Ravenstein², Gagandeep Chadha¹

¹Department of Cardiology, Amiens University Hospital, Amiens, France.

JACC. Cardiovascular Imaging

|November 19, 2018

Insights

A left ventricular ejection fraction (LVEF) below 55% indicates poor prognosis in severe aortic stenosis patients with preserved LVEF. Early surgical intervention is recommended before LVEF drops below this threshold.

Area of Science:

Cardiology
Echocardiography
Cardiac Surgery

Background:

Severe aortic stenosis (AS) with preserved LVEF (≥50%) is uncommon.
Current guidelines recommend aortic valve replacement (AVR) for LVEF <50%, but data on LVEF thresholds in preserved LVEF are lacking.

Purpose of the Study:

To identify the optimal left ventricular ejection fraction (LVEF) cutoff for predicting long-term mortality in severe AS patients with preserved LVEF.
To evaluate the prognostic value of LVEF in patients managed conservatively or surgically.

Main Methods:

Analysis of 1,678 patients with severe AS and preserved LVEF.
Patients were stratified into three groups based on LVEF: <55%, 55%-59%, and ≥60%.

Main Results:

Five-year survival rates were significantly lower for patients with LVEF <55% (59 ± 4%) compared to LVEF ≥60% (72 ± 2%).
LVEF <55% was associated with significantly increased mortality under both conservative and surgical management.
Patients with LVEF 55%-59% had a similar prognosis to those with LVEF ≥60%.

Conclusions:

A left ventricular ejection fraction (LVEF) below 55% is a marker of poor prognosis in severe AS patients with preserved LVEF.
These findings suggest considering surgical intervention before LVEF declines below 55% in this patient group.

Read full analysis

Abstract

Objectives:

This study sought to determine the best left ventricular ejection fraction (LVEF) cutoff value to predict long-term mortality in patients with asymptomatic or minimally symptomatic severe aortic stenosis (AS) and LVEF ≥50% under conservative management and after surgical correction of AS.

Background:

Aortic valve replacement (AVR) is a Class I indication in asymptomatic patients with severe AS and LVEF <50%. However, this is an uncommon situation in asymptomatic severe AS (<1% of patients), usually occurring late in the course of the disease. No data are available concerning the prognostic value of LVEF in asymptomatic or minimally symptomatic AS patients with preserved LVEF (≥50%) in order to identify a LVEF threshold value associated with increased mortality.

Methods:

This analysis included 1,678 patients with preserved LVEF and no or minimal symptoms, with a diagnosis of severe AS. The population was divided into 3 groups: LVEF <55%, LVEF 55% to 59%, and LVEF ≥60%.

Results:

Five-year survival rate was 72 ± 2% for patients with LVEF ≥60%, 74 ± 2% for patients with LVEF between 55% and 59%, and 59 ± 4% for patients with LVEF <55% (p < 0.001). Under initially conservative or initially surgical management (surgery within 3 months after baseline echocardiography), patients with LVEF <55% displayed significant excess mortality compared to patients with LVEF≥ 60% (adjusted hazard ratio [HR]: 2.44 [95% confidence interval: 1.51 to 3.94]; p < 0.001 and 2.51 [95% confidence interval: 1.58 to 4.00]; p < 0.001, respectively), whereas patients with LVEF between 55% and 59% had comparable prognosis to those with LVEF ≥60% (p = 0.53 and p = 0.36, respectively). In patients with LVEF <55%, initial conservative management was associated with increased mortality compared to initial surgical management, even after covariate adjustment (adjusted hazard ratio [HR]: 2.70 [95% confidence interval: 1.98 to 3.67]; p < 0.001).

Conclusions:

In patients with severe AS, preserved LVEF and no or minimal symptoms at the time of diagnosis, LVEF <55% is a marker of poor outcome, with medical or surgical management suggesting that these patients should be considered for surgery before this stage.

Keywords:

aortic stenosis conservative management left ventricular ejection fraction mortality prognosis surgery

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