The presence of aortic stenosis, heart failure, and decreased ventricular function is associated with poor prognosis and high mortality. For this reason, both European and American guidelines classify severe stenosis as a Class I indication.
There are two retrospective analyses that demonstrate the benefits of transcatheter aortic valve implantation (TAVI) via transfemoral access. The TAVR UNLOAD study is currently ongoing, so we still lack enough information in this scenario and do not know which groups would benefit from this strategy.
An analysis was conducted using data from the ATLAS TAVI (Anatomic Stenosis Severity as a Prognostic Marker in Patients With Low-Flow Low-Gradient Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation) Registry and a registry carried out in Canada. It included 1,176 patients with moderate or severe aortic stenosis and reduced ejection fraction who underwent TAVI via transfemoral access or medical treatment.
Patients were divided into three groups: 527 patients with severe aortic stenosis, low gradient, and reduced ejection fraction who underwent TAVI (TS-LAGS TAVI), 179 patients with pseudosevere or moderate aortic stenosis, low gradient, and decreased ejection fraction who underwent TAVI (PS-LGAS TAVI), and 470 patients with severe or moderate aortic stenosis and decreased ejection fraction who received medical treatment (Medical-Mood).
The primary endpoint was all-cause mortality and cardiac mortality at two years.
The populations were different.
After two years of follow-up, all-cause mortality was similar in all three groups, but cardiovascular mortality was lower for those who underwent TAVI (TS-LGAS, hazard ratio [HR]: 0.32 [95% confidence interval [CI]: 0.17-0.59]; p < 0.0001; PS-LGAS, HR: 0.34 [95% CI: 0.16-0.72]; p < 0.0001) compared with the medical treatment group.
Age, atrial fibrillation, coronary artery disease, chronic obstructive pulmonary disease (COPD), stroke, and functional class were predictors of all-cause mortality and cardiovascular mortality.
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Propensity score matching was performed between the PS-LGAS TAVI group and the Medical-Mood group. All-cause mortality and cardiovascular mortality at two years were lower in those who underwent TAVR (all-cause mortality: 48.8% vs. 65.4%, p < 0.0001; cardiovascular mortality: 19.6% vs. 41.56%, p = 0.004, respectively).
Conclusion
In patients with non-severe aortic stenosis and decreased ejection fraction, TAVI emerges as a major predictor of survival. These results reinforce the need for randomized controlled trials assessing TAVI versus medical treatment in patients with heart failure and non-severe aortic stenosis.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Transcatheter Aortic Valve Replacement in Patients With Reduced Ejection Fraction and Nonsevere Aortic Stenosis.
Reference: Sebastian Ludwig, et al. Circ Cardiovasc Interv. 2023;16:e012768. DOI: 10.1161/CIRCINTERVENTIONS.122.012768.
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