Valvular Heart Disease
Prognostic Significance of Atrial Fibrillation and Severity of Symptoms of Heart Failure in Patients With Low Gradient Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

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The aims of this study were to investigate the clinical outcomes of patients with low-gradient aortic stenosis despite preserved left ventricular ejection fraction and to assess reliable prognostic clinical-instrumental features in patients experiencing or not experiencing aortic valve replacement (AVR). Clinical-laboratory and echocardiographic data from 167 patients (median age 78 years, interquartile range 69 to 83) with aortic valve areas <1.0 cm2, mean gradients ≤30 mm Hg, and preserved left ventricular ejection fraction (≥55%), enrolled from 2005 to 2010, were analyzed. During a mean follow-up period of 44 ± 23 months, 33% of patients died. On multivariate analysis, independent predictors of death were baseline New York Heart Association functional class III or IV (hazard ratio 2.16, p = 0.038) and atrial fibrillation (hazard ratio 2.00, p = 0.025). Conversely, AVR was protective (hazard ratio 0.25, p = 0.01). The magnitude of the protective effect of AVR seemed to be relatively more important in patients with atrial fibrillation than in those in sinus rhythm, independently of the severity of symptoms. Age >70 years showed a trend toward being a prognostic predictor (p = 0.082). In conclusion, in patients with low-gradient aortic stenosis despite a preserved left ventricular ejection fraction, AVR was strongly correlated with a better prognosis. Patients with atrial fibrillation associated with advanced New York Heart Association class had the worst prognosis if treated medically but at the same time a relative better benefit from surgical intervention.

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Methods

We analyzed our database to evaluate clinical, echocardiographic, and biohumoral data from patients with LG AS despite normal LVEF observed in our department from January 2005 to December 2010. Inclusion criteria were (1) aortic valve area (AVA; measured by the continuity equation) <1.0 cm2, (2) mean gradient (MG) ≤30 mm Hg, and (3) LVEF ≥55%. We arbitrarily decided to adopt strict enrollment criteria to minimize the burden of measurement errors. Moreover, for the same reason, the inclusion

Results

Over the considered 5-year period of analysis, within the cohort of 1,149 consecutive patients with severe AS (AVA <1 cm2) observed in the echocardiography laboratory of our department, we retrospectively identified 397 patients (35%) with LG (≤30 mm Hg); among this group, we included 167 patients (15%) with LG AS and normal LVEF (≥55%), matching the above-mentioned enrollment criteria (see Figure 1).

Complete baseline clinical and laboratory data are listed in Table 1. The median age of our

Discussion

With the present study, we proposed to carry out a comprehensive clinical and echocardiographic analysis of a large cohort of patients with LG AS despite normal LVEF, to better understand prognostic factors and therapeutic strategies in this difficult subset. The enrollment and exclusion criteria we arbitrarily decided to adopt were aimed to eliminate possible confounding factors (e.g., LVEF 50% to 54%, MG 31 to 39 mm Hg) but, at the same time, to obtain a population that is intended to be

Disclosures

The authors have no conflicts of interest to disclose.

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