Clinical outcomes and revascularization strategies in patients with low-flow, low-gradient severe aortic valve stenosis according to the assigned treatment modality.

Abstract

This study compared clinical outcomes and revascularization strategies among patients presenting with low ejection fraction, low-gradient (LEF-LG) severe aortic stenosis (AS) according to the assigned treatment modality. The optimal treatment modality for patients with LEF-LG severe AS and concomitant coronary artery disease (CAD) requiring revascularization is unknown. Of 1,551 patients, 204 with LEF-LG severe AS (aortic valve area<1.0 cm(2), ejection fraction<50%, and mean gradient<40 mmHg) were allocated to medical therapy (MT) (n= 44), surgical aortic valve replacement (SAVR) (n=52), or transcatheter aortic valve replacement (TAVR) (n= 108). CAD complexity was assessed using the SYNTAX score (SS) in 187 of 204 patients (92%). The primary endpoint was mortality at 1 year. LEF-LG severe AS patients undergoing SAVR were more likely to undergo complete revascularization (17of52,35%) compared with TAVR (8 of 108, 8%) and MT (0 of 44, 0%) patients (p< 0.001). Compared with MT, bothSAVR (adjusted hazard ratio [adj HR]: 0.16; 95% confidence interval [CI]: 0.07 to 0.38; p< 0.001) and TAVR (adjHR: 0.30; 95% CI: 0.18 to 0.52; p< 0.001) improved survival at 1 year. In TAVR and SAVR patients, CAD severity wasassociated with higher rates of cardiovascular death (no CAD: 12.2% vs. low SS [0 to 22], 15.3% vs. high SS [>22], 31.5%; p= 0.037) at 1 year. Compared with no CAD/complete revascularization, TAVR and SAVR patients undergoing incomplete revascularization had significantly higher 1-year cardiovascular death rates (adj HR: 2.80; 95% CI: 1.07 to 7.36; p= 0.037). Among LEF-LG severe AS patients, SAVR and TAVR improved survival compared with MT. CAD severity was associated with worse outcomes and incomplete revascularization predicted 1-year cardiovascular mortality among TAVR and SAVR patients.