Original title: Relation of Pre-procedural Assessment of Myocardial Contractility Reserve on Outcomes of Aortic Stenosis Patients with Impaired Left Ventricular Function Undergoing Transcatheter Aortic Valve Implantation Reference: Israel M. Barbash et al. Am J Cardiol. 2014, Epub ahead of print.
Transcatheter aortic valve replacement (TAVI) is associated with a better left ventricular function (LV) in patients with aortic stenosis (AS) and LV dysfunction; however, post-TAVI clinical outcomes in patients with low ejection fraction (LVEF) are still under discussion.
This study evaluated the baseline procedural and long term outcomes of patients with low LVEF undergoing TAVI and the prognostic use of pre TAVI balloon aortic valvuloplasty (BAV) and dobutamine stress echocardiography (DSE) to predict TAVI benefit.
All severe symptomatic AS patients undergoing TAVI between 2007 and 2013 were analyzed. Two groups were compared: the normal group, with normal LV function (LVEF > 45 %) and abnormal (LVEF ≤ 45 %) at baseline. 371 patients were included, 272 (73 %) had preserved LVEF and 99 (27%) low had LVEF. Patients with low LVEF had higher Society of Thoracic Surgeons Score and EuroSCORE.
Short and long term mortality was similar in both groups (one year mortality: 22,2 % normal LVEF vs. 22,4 % abnormal LVEF, p = 0,79). In the low LVEF group, 24% of patients showed improvement at 30 days (≥ 10 %). This group had a lower rate of one year mortality compared to those that did not show LVEF improvement (8 % vs 27 %, p = 0,06).
On the other hand, contractile reserve in dobutamine stress echocardiography did not predict LVEF recovery in patients with low LVEF, but did predict lower mortality. LVEF recovery after TAVI was able to predict greater improvement of post TAVI LVEF.
Conclusion
Patients with severe AS and impaired LV function will benefit from TAVI and their post TAVI outcomes are comparable to those of patients with preserved LVEF. Both DES and TAVI provide complementary data with regard to LVEF recovery and peri procedural mortality.
Editorial Comment
We often wonder what the outcome our low LVEF patients will be after TAVI and in this study we can see that, globally, mortality rate is similar to that of preserved LVEF patients, which is not the case of surgical aortic valve replacement, since LVEF predicts worse outcomes and higher mortality both in STS and EuroScore.
Although only 25% of patients recovered more than 10 % of LVEF at 30 days, the global benefit could be seen in the whole group, and patients that improved LVEF had lower mortality. Pre TAVI aortic valvuloplasty seems to be a good tool to tell patients that will improve LVEF after TAVI from those who will not. The rise of contractility with dobutamine (contractility reserve) seems a good tool to predict lower mortality, though it will not assure LVEF recovery.
Courtesy of Dr. Matías Sztejfman.
Interventional Cardiologist.
Sanatorio Güemes. Buenos Aires, Argentina.
Dr. Matías Sztejfman