Abstract 18816: Relationship of Aortic Valve Surgery and Survival in Patients with Moderate or Severe Aortic Stenosis and Left Ventricular Dysfunction

Abstract

Introduction: Aortic valve replacement (AVR) for aortic stenosis (AS) carries additional surgical risk in patients with left ventricular dysfunction (LVD) but has been associated with survival benefit. The current use of AVR and its relationship to mortality in patients with moderate or severe AS and LVD is ill defined. Hypothesis: We hypothesized that AVR was underutilized among patients with moderate/severe AS and LVD, and that it was associated with lower mortality. Methods: We queried the Duke Echocardiographic Database for patients with moderate (mean gradient >25 mmHg and/or peak velocity >3m/s) or severe AS (mean gradient >40 mmHg and or peak velocity >4m/s) and LVD (left ventricular ejection fraction [LVEF] <50%) from 1/1/1995-5/1/2014. We used multivariable Cox modeling to assess the relationship of AVR and all-cause mortality. Results: We identified a total of 1,634/132,804 patients with moderate (1,095, 67%) or severe (539, 33%) AS and LVD. Severe LVD (LVEF ≤35%) was present in 35% of the cohort. The median age of the cohort was 75 (IQR 67-83), and patients with moderate AS were more likely than those with severe AS to have a history of ischemic heart disease, diabetes, peripheral vascular disease, cerebrovascular disease, and renal disease (all p <0.01). Median logistic EuroSCORE was 9.8 (5.5, 16.8). Median follow-up time was 1.2 years (IQR 0.2- 3.9). There were 863 deaths in the cohort. Overall, 287 (26%) patients with moderate AS and 263 (48%) patients with severe AS underwent AVR within 5 years of the qualifying echo. After multivariable adjustment, AVR with (n=270) or without CABG (n=280), compared to medical therapy was associated with lower mortality (HR=0.47 [0.38, 0.59], p<0.0001) in the entire cohort. Compared to CABG alone, the combination of CABG + AVR (HR=0.19 [0.14, 0.27], p<0.0001) was associated with a significant survival advantage. Conclusions: Among patients with significant AS and LVD, AVR with or without CABG is associated with significant mortality benefit and may be underutilized in this population. Further research is required to understand factors contributing to current practice patterns and the possible utility of transcatheter approaches in this high-risk cohort.