Initial Aortic Valve Replacement Research Articles

The Northern New England Rapid Deployment Valve Experience: Survival and Procedural Outcomes From 2015 to 2021.

The optimal approach and choice of initial aortic valve replacement (AVR) is evolving in the growing era of transcatheter AVR. Further survival and hemodynamic data are needed to compare the emerging role of rapid deployment (rdAVR) versus stented (sAVR) valve options for AVR. The Northern New England Cardiovascular Database was queried for patients undergoing either isolated AVR or AVR + coronary artery bypass grafting (CABG) with rdAVR or sAVR aortic valves between 2015 and 2021. Exclusion criteria included endocarditis, mechanical valves, dissection, emergency case status, and prior sternotomy. This resulted in a cohort including 1,616 sAVR and 538 rdAVR cases. After propensity weighting, procedural characteristics, hemodynamic variables, and survival outcomes were examined. The breakdown of the overall cohort (2,154) included 1,164 isolated AVR (222 rdAVR, 942 sAVR) and 990 AVR + CABG (316 rdAVR, 674 sAVR). After inverse propensity weighting, cohorts were well matched, notable only for more patients <50 years in the sAVR group (4.0% vs 1.9%, standardized mean difference [SMD] = -0.12). Cross-clamp (89 vs 64 min, SMD = -0.71) and cardiopulmonary bypass (121 vs 91 min, SMD = -0.68) times were considerably longer for sAVR versus rdAVR. Immediate postreplacement aortic gradient decreased with larger valve size but did not differ significantly between comparable sAVR and rdAVR valve sizes or overall (6.5 vs 6.7 mm Hg, SMD = 0.09). Implanted rdAVR tended to be larger with 51% either size L or XL versus 37.4% of sAVR ≥25 mm. Despite a temporal decrease in pacemaker rate within the rdAVR cohort, the overall pacemaker frequency was less in sAVR versus rdAVR (4.4% vs 7.4%, SMD = 0.12), and significantly higher rates were seen in size L (10.3% vs 3.7%, P < 0.002) and XL (15% vs 5.6%, P < 0.004) rdAVR versus sAVR. No significant difference in major adverse cardiac events (4.6% vs 4.6%, SMD = 0.01), 30-day survival (1.5% vs 2.6%, SMD = 0.08), or long-term survival out to 4 years were seen between sAVR and rdAVR. Rapid deployment valves offer a safe alternative to sAVR with significantly decreased cross-clamp and cardiopulmonary bypass times. Despite larger implantation sizes, we did not appreciate a comparative difference in immediate postoperative gradients, and although pacemaker rates are improving, they remain higher in rdAVR compared with sAVR. Longer-term hemodynamic and survival follow-up are needed.

Prognostic Value of NT-proBNP in Asymptomatic Patients with Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Background: The aortic valve replacement (AVR) indication in asymptomatic patients with severe aortic stenosis (AS) and preserved function is being increasingly discussed. Objective: The aim of this study was to evaluate whether the elevation of N-terminal fraction of the pro-B-type natriuretic peptide (NT-proBNP) predicts the occurrence of symptoms and the AVR indication in patients with severe AS and preserved left ventricular ejection fraction (LVEF), initially asymptomatic. Methods: Asymptomatic patients with severe AS, preserved LVEF (≥55%) and no initial AVR indication were prospectively included. All patients underwent laboratory tests measuring NT-proBNP at baseline, and an echocardiogram with tissue Doppler recording the lateral wall S wave (lat. S) and the E/e´ ratio. The endpoint was the aortic valve replacement indication at follow-up. Results: We included 133 patients aged 69 ± 8 years, 49% of which were women. After a follow-up of 570 (interquartile range 380-680) days, 23.3% (n=31) of them required aortic valve replacement. In the multivariate analysis, NT-proBNP value and the E/e' ratio were independent predictors of surgery (HR 1.02, 95% CI 1.001-1.03, p&lt;0.001 and HR 1.42, 95% CI 1.21-2.45, p&lt; 0.001, respectively). NT-proBNP presented an area under the curve (AUC) greater than the E/e’ ratio (0.88 versus 0.64, p=0.02). The best NT-proBNP cut-off point was determined as &gt;350 pg./mL (adjusted HR 1.55, 95% CI 1.38-2.01, p&lt;0.001). Conclusion: NT-proBNP value and the E/e' ratio were independent predictors of AVR requirement. NT-proBNP had a very good discrimination capacity, greater than the E/e´ ratio

71-Year-Old Man With a New Heart Murmur

71-Year-Old Man With a New Heart Murmur

Atrial fibrillation in patients with severe aortic stenosis

BackgroundThere has been no previous report evaluating the long impact of atrial fibrillation (AF) on the clinical outcomes stratified by the initial management [conservative or aortic valve replacement (AVR)] strategies of severe aortic stenosis (AS). MethodsWe analyzed 3815 patients with severe AS enrolled in the CURRENT AS registry. Patients with AF were defined as those having a history of AF when severe AS was found on the index echocardiography. The primary outcome measure was a composite of aortic valve–related death or hospitalization for heart failure. ResultsThe cumulative 5-year incidence of the primary outcome measure was significantly higher in patients with AF than in those without AF (44.2 % versus 33.2 %, HR 1.54, 95 % CI 1.35–1.76). After adjusting for confounders, the risk of AF relative to no AF remained significant (HR 1.34, 95 % CI 1.16–1.56). The magnitude of excess adjusted risk of AF for the primary outcome measure was greater in the initial AVR stratum (N = 1197, HR 1.95, 95 % CI 1.36–2.78) than in the conservative stratum (N = 2618, HR 1.26, 95 % CI 1.08–1.47) with a significant interaction (p = 0.04). In patients with AF, there was a significant excess adjusted risk of paroxysmal AF (N = 254) relative to chronic AF (N = 528) for the primary outcome measure (HR 1.34, 95 % CI 1.01–1.78). ConclusionsIn patients with severe AS, concomitant AF was independently associated with worse clinical outcomes regardless of the initial management strategies. In those patients with conservative strategy, paroxysmal AF is stronger risk factor than chronic AF.

Concomitant Mitral Regurgitation in Severe Aortic Stenosis - A Report From the CURRENT AS Registry.

The clinical significance of concomitant mitral regurgitation (MR) has not been well addressed in patients with severe aortic stenosis (AS).Methods and Results:We analyzed 3,815 patients from a retrospective multicenter registry of severe AS in Japan (CURRENT AS registry). We compared the clinical outcomes between patients with moderate/severe MR and with none/mild MR according to the initial treatment strategy (initial aortic valve replacement [AVR] or conservative strategy). The primary outcome measure was a composite of aortic valve-related death or heart failure hospitalization. At baseline, moderate/severe MR was present in 227/1,197 (19%) patients with initial AVR strategy and in 536/2,618 (20%) patients with a conservative strategy. The crude cumulative 5-year incidence of the primary outcome measure was significantly higher in patients with moderate/severe MR than in those with none/mild MR, regardless of the initial treatment strategy (25.2% vs. 14.4%, P<0.001 in the initial AVR strategy, and 63.3% vs. 40.7%, P<0.001 in the conservative strategy). After adjusting confounders, moderate/severe MR was not independently associated with higher risk for the primary outcome measure in the initial AVR strategy (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.67-1.83, P=0.69), and in the conservative strategy (HR 1.13, 95% CI 0.93-1.37, P=0.22). Concomitant moderate/severe MR was not independently associated with higher risk for the primary outcome measure regardless of the initial treatment strategy.

The need for future coronary access following surgical or transcatheter aortic valve replacement.

The aim of the study was to estimate the percentage of Medicare patients needing coronary access for percutaneous coronary intervention (PCI) or coronary angiography following aortic valve replacement (AVR). Indications for TAVR have expanded to include younger and low-risk patients, raising the question of coronary access for future procedures. Medicare patients <80 years old with an AVR between 2011 and 2018 were included. Time-to-event analyses were conducted using Cox hazard models to estimate risk of coronary access up to 7 years after AVR. Model adjustments included age, sex, race, region, comorbidity, concomitant CABG, and smoking. A total of 13,469 Medicare patients (mean age 70.6) met inclusion criteria. Models estimated that 2.5% of patients at 1-year post-index and 17% at over 7 years would need coronary access. For patients who had SAVR (with or without CABG), estimates for coronary access were similar and over 15% after 6.5 years. For TAVR patients, with a previous PCI, 28% at 4.5 years required coronary access, which was higher than TAVR patients without a previous PCI. SAVR patients with and without CAD at baseline were similar; however, TAVR patients with CAD had a 22% rate of coronary access versus 7% for those without at 3 years. Approximately half of patients who needed coronary access returned to the same hospital as their initial AVR. Coronary access is required in a substantial portion of AVR patients especially those with PCI or a history of CAD undergoing TAVR. The need for coronary access may increase as transcatheter AVR becomes accessible to younger patients with a longer life expectancy.

Cardiac surgery following transcatheter aortic valve replacement.

The objective of this study was to retrospectively analyse surgical outcomes of patients undergoing secondary cardiac surgery after initial transcatheter aortic valve replacement (TAVR). Between December 2012 and February 2020, a total of 41 consecutive patients underwent cardiac surgery after a TAVR procedure at our institution. Patients who underwent emergency operations due to periprocedural complications such as ventricular rupture and TAVR dislocation were excluded from this study (n = 12). Thus, 29 patients were included in the analysis. Data are presented as medians (25th-75th quartiles) or as absolute numbers (percentages). The median age was 76 years (68-80); 58.6% were men. The median time to a secondary conventional procedure was 23 months (8-40), with 8 patients requiring surgical intervention within the first year post TAVR. The indications for secondary conventional procedures were prosthesis endocarditis (n = 15), prosthesis degeneration or dysfunction (n = 7) and progression of valvular, aortic or coronary artery disease (n = 7). Surgical redo aortic valve replacement was performed in 24 patients (82.8%). No complications involving the aortic root or the aortomitral continuity were observed. The operative mortality was 10.3%. Extracorporeal life support was required in 3 patients (10.3%) for a median duration of 3 days (3-3 days). No adverse cerebrovascular events were observed postoperatively. Postoperatively, 4 patients (13.8%) required a pacemaker and 7 patients (24.1%) required renal replacement therapy. Overall survival at 1 year was 83.0%. Conventional cardiac surgical procedures following TAVR are feasible with reasonable results and a low complication rate.

Konno-rastan procedure combined with manougian root enlargement for small aortic root

Aortic stenosis is a rarely seen condition in the pediatric population. Valve replacement is a treatment option for patients who do not benefit from medical or interventional procedures. In this report, we described our surgical treatment strategy in a 17-year-old patient who developed patient-prosthesis mismatch long after initial aortic valve replacement during the childhood period. Keywords: Konno-rastan procedure; manouguian technique; aortic root enlargement

Impact of concomitant mitral regurgitation in severe aortic stenosis in Japan – from the CURRENT AS registry

Abstract Background Clinical significance of concomitant mitral regurgitation (MR) in patients with severe aortic stenosis (AS) has not been well-studied. Purpose The purpose of this study is to investigate the prognostic impact of concomitant MR in patients with severe AS. Method We used the data of 3815 patients from the CURRENT AS registry, a retrospective multicenter registry of severe AS in Japan. We compared the clinical outcomes between patients with moderate/severe MR and with none/mild MR according to the initial treatment strategies (initial aortic valve replacement [AVR] or conservative strategy). The primary outcome measure was a composite of aortic valve-related death and heart failure hospitalisation. Results Among the study population, moderate/severe MR were observed in 227/1197 (19%) patients with initial AVR strategy and in 536/2618 (20%) patients with conservative strategy. Among survivors with the initial AVR strategy, moderate/severe MR improved in 61/62 (98%) patients with concomitant mitral procedures. The crude cumulative 5-year incidence of the primary outcome measure was significantly higher in patients with moderate/severe MR than in those with none/mild MR regardless of the treatment strategies (25.2% vs. 14.4%, P&amp;lt;0.001 in the initial AVR strategy; 63.3% vs 40.7%, P&amp;lt;0.001 in the conservative strategy). Multivariate analysis revealed moderate/severe MR at index echocardiography was independently associated with higher risk for the primary outcome measure in conservative strategy (adjusted HR 1.20, 95% CI 1.03–1.40, P=0.023), but not associated in the initial AVR strategy (adjusted HR 1.20, 95% CI 0.82–1.80, P=0.339). Conclusion Moderate/severe MR was independently associated with poorer outcome in patients with severe AS who were managed conservatively, but not in those with initial AVR strategy. Funding Acknowledgement Type of funding source: None

Transcatheter ViV Versus Redo Surgical AVR for the Management of Failed Biological Prosthesis: Early and Late Outcomes in a Propensity-Matched Cohort

ObjectivesThe aim of this study was to compare early and late outcomes between redo surgical aortic valve replacement (AVR) and valve-in-valve (ViV) transcatheter AVR. BackgroundPublished studies to date comparing redo surgical AVR (RS) with ViV transcatheter AVR for failed biological prostheses have been small and limited to early outcomes. MethodsClinical and administrative databases for Ontario, Canada’s most populous province, were linked to obtain patients undergoing ViV and RS for failed previous biological prostheses. Propensity score matching was performed to account for differences in baseline characteristics. Early outcomes were compared using the McNemar test. Late mortality was compared between the matched groups using a Cox proportional hazards model. ResultsA total of 558 patients undergoing intervention for failed biological prostheses between March 31, 2008, and September 30, 2017, at 11 Ontario institutions (ViV, n = 214; RS, n = 344) were included. Patients who underwent ViV were older and had more comorbidities. Propensity matching on 27 variables yielded similar groups for comparison (n = 131 pairs). Mean time from initial AVR to RS or ViV was 8.6 ± 4.4 years and 11.3 ± 4.5 years, respectively. Thirty-day mortality was significantly lower with ViV compared with RS (absolute risk difference: −7.5%; 95% confidence interval: −12.6% to −2.3%). The rates of permanent pacemaker implantation and blood transfusions were also lower with ViV, as was length of stay. Survival at 5 years was higher with ViV (76.8% vs. 66.8%; hazard ratio: 0.55; 95% confidence interval: 0.30 to 0.99; p = 0.04). ConclusionsViV TAVR was associated with lower early mortality, morbidity, and length of hospital stay and with increased survival compared with RS and may be the preferred approach for the treatment of failed biological prostheses.

Open hemiarch versus clamped ascending aorta replacement for aortopathy during initial bicuspid aortic valve replacement

BackgroundThere is controversy regarding the extent of aortic resection necessary in patients with aortopathy related to bicuspid aortic valve disease. To address this issue, we reviewed our experience in patients undergoing ascending aorta replacement during bicuspid aortic valve replacement. MethodsWe reviewed 702 patients who underwent ascending aorta replacement at the time of initial nonemergent native bicuspid aortic valve replacement at our institution between January 2000 and June 2017. Treatment cohorts included an open hemiarch replacement group (n = 225; 32%) and a clamped ascending aorta replacement group (n = 477; 68%). ResultsMedian patient age was 60 years (interquartile range [IQR], 51-67 years), female sex was present in 113 patients (16%), ejection fraction was 62% (IQR, 56%-66%), and aortic arch diameter was 33 mm (IQR, 29-36 mm). Cardiopulmonary bypass time was longer in the hemiarch replacement group (188 minutes vs 97 minutes; P < .001). Procedure-related complications (36%) and mortality (<1%) were similar in the 2 groups; however, the hemiarch group had an increased odds of blood transfusion (odds ratio, 1.62; 95% confidence interval [CI], 1.15-2.28; P = .006). The median duration of follow-up was 6.0 years (95% CI, 5.3-6.8 years). Overall survival was 94 ± 1% at 5 years and 80 ± 2% at 10 years. Multivariable analysis demonstrated similar survival in the 2 groups (hazard ratio, 0.83; 95% CI, 0.51-1.33; P = .439). No repeat aortic arch operations were done for aortopathy over the duration of clinical follow-up. ConclusionsCompared with patients in the clamped ascending aorta replacement group, patients in the hemi-arch replacement group had longer cardiopulmonary bypass and aortic cross-clamp times, along with an increased risk of blood transfusion, but similar freedom from repeat aortic arch operation and survival. We identified no advantage of performing hemiarch replacement in the absence of aortic arch dilation.

The fate of mild to moderate proximal aortic dilatation after isolated aortic valve replacement in tricuspid aortic valve patients.

Proximal aortic dilatation is frequently associated with aortic valve pathology. The treatment of mild to moderate proximal aortic dilatation (maximal diameter: 40-50 mm) at the time of aortic valve replacement (AVR) is still controversial. We retrospectively analyzed the fate and progression of the proximal dilated aorta after isolated AVR in tricuspid aortic valve (TAV) patients, to determine if ascending aortic replacement (AAR) is recommended at the time of the initial AVR. The review of our hospital database revealed a subgroup of 127 TAV disease patients with mild to moderate ascending aortic dilatation, who underwent isolated AVR (group I, n = 68) or AVR combined AAR (group II, n = 59) from January 2000 to December 2013. Follow-up was obtained through a telephone interview/outpatient interview. Adverse aortic events were defined as aortic dissection/ rupture, or diameter of proximal aorta ≥55 mm, or re-do aortic surgery contributable to the dilated aorta during follow-up. There were no differences in age, gender, heart function, hypertension, diabetes, smoking, chronic renal failure, and atrium fibrillation between two groups except for the maximum aortic diameter (group I 43.91 ± 2.0 vs group II 45.20 ± 2.63, P < .05). The cross-clamp time and cardiopulmonary bypass time was significantly less in group I than that in group II, owing to the replacement of the proximal aorta. A total of 126 patients were discharged home successfully, with 0.79% hospital mortality. There was no significant difference of hospital mortality and morbidity between the two groups. Follow-up was successfully obtained in 106 patients (84.13%). Mean follow-up time was (9.60 ± 3.47) years. The overall survival at 10-year follow-up was 72.46% ± 6.42% in group I versus 74.55% ± 6.87% in group II ( P = .73). The freedom from adverse aortic events at 10-year was 89.59% ± 4.02% in group I versus 96.88% ± 3.07% in group II ( P = .09). No significant difference in survival rate and freedom from adverse aortic events can be obtained between the two groups. Progression of proximal aorta leading to adverse aortic events after isolated AVR in TAV patients is infrequent. AVR alone is acceptable and reasonable in patients with mild to moderate proximal aortic dilatation if connective tissue disorders are not present.

Reasons for Choosing Conservative Management in Symptomatic Patients With Severe Aortic Stenosis - Observations From the CURRENT AS Registry.

There has not been a previous report on the long-term outcomes of those patients who refuse aortic valve replacement (AVR) despite physicians' recommendations.Methods and Results:Among 3,815 consecutive patients with severe aortic stenosis (AS) enrolled in the CURRENT AS registry, the study population comprised 2,005 symptomatic patients, who were subdivided into 3 groups by their treatment strategy and the reasons for conservative strategy (Initial AVR group: n=905; Patient rejection group: n=256; Physician judgment group, n=844). The primary outcome measure was a composite of aortic valve-related death and heart failure hospitalization. Patients in the patient rejection group as compared with those in the physician judgment group were younger, and had less comorbidities, and lower surgical risk scores. The cumulative 5-year incidence of the primary outcome measure in the patient rejection group was markedly higher than that in the initial AVR group, and was similar to that in the physician judgment group (60.7%, 19.0%, and 66.4%, respectively). Patient rejection was the reason for non-referral to AVR in nearly one-quarter of the symptomatic patients with severe AS who were managed conservatively. The dismal outcome in patients who refused AVR was similar to that in patients who were not referred to AVR based on physician judgment despite less comorbidities and lower surgical risk scores in the former than in the latter.

Anemia in Patients with Severe Aortic Stenosis

Prognostic impact of anemia complicating severe aortic stenosis (AS) remains unclear. We assessed the impact of anemia on cardiovascular and bleeding outcomes in 3403 patients enrolled in the CURRENT AS registry. 835 patients (25%) had mild (hemoglobin 11.0–12.9 g/dl for men/11.0–11.9 g/dl for women) and 1282 patients (38%) had moderate/severe anemia (Hb ≤ 10.9 g/dl) at diagnosis of severe AS. Mild and moderate/severe anemia were associated with significantly increased risks relative to no anemia (hemoglobin ≥13.0 g/dl for men/≥12.0 g/dl for women) for the primary outcome measure (aortic valve-related death or heart failure hospitalization) in the entire population [hazard ratio (HR): 1.30; 95% confidence interval (CI): 1.07–1.57 and HR: 1.56; 95%CI: 1.31–1.87, respectively] and in the conservative management stratum (HR: 1.73; 95%CI: 1.40–2.13 and HR: 2.05; 95%CI: 1.69–2.47, respectively). Even in the initial aortic valve replacement stratum, moderate/severe anemia was associated with significantly increased risk for the primary outcome measure (HR: 2.12; 95%CI: 1.44–3.11). Moreover, moderate/severe anemia was associated with significantly increased risk for major bleeding while under conservative management (HR: 1.93; 95%CI: 1.21–3.06). These results warrant further study to explore whether better management of anemia would lead to improvement of clinical outcomes.

The Effect of Post-Dilatation on Outcomes in the PARTNER 2 SAPIEN 3 Registry

ObjectivesThe purpose of this study was to understand the effects of balloon post-dilatation on outcomes following transcatheter aortic valve replacement with the SAPIEN 3 valve. BackgroundHemodynamics and outcomes with balloon post-dilatation for the SAPIEN 3 valve have not been previously reported. MethodsThe effects of balloon post-dilatation (BPD) in 1,661 intermediate (S3i cohort) and high surgical risk (S3HR cohort) patients with aortic stenosis enrolled in the PARTNER (Placement of Aortic Transcatheter Valves) 2, SAPIEN 3 observational study on outcomes, as well as procedural complications, were assessed. Results208 of 1,661 patients (12.5%) had BPD during the initial transcatheter aortic valve replacement. Baseline characteristics were similar except BPD had higher STS score (p < 0.001), significantly less % oversizing (p = 0.004), significantly more ≥moderate left ventricular outflow tract calcification (p = 0.005), and severe annular calcification (p = 0.006). BPD patients had no increase in permanent pacemaker, annular rupture, or valve embolization. Following transcatheter aortic valve replacement, BPD patients had significantly larger aortic valve area (1.72 ± 0.41 cm2 vs. 1.66 ± 0.37 cm2; p = 0.04) with no significant difference in prosthesis–patient mismatch (p = 0.08) or transvalvular aortic regurgitation (p = 0.65), but significantly more paravalvular regurgitation (p < 0.01). There was no significant difference in 30-day or 1-year outcomes of all-cause death (p = 0.65 to 0.76) or stroke (p = 0.28 to 0.72). However, at 1 year, there was a significantly higher incidence of minor stroke in BPD patients (p = 0.02). Adjusting for baseline differences, including calcium burden, minor strokes were no longer significantly different between the BPD and NoBPD groups (p = 0.21). ConclusionsBPD is performed more frequently in patients with lower % oversizing and greater calcium burden. BPD is not associated with procedural complications or an increase in 1-year adverse events of death, rehospitalization, or stroke.

Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Severe Aortic Stenosis

ObjectivesThe aim of this study was to evaluate the prognostic impact of left ventricular ejection fraction (LVEF) in patients with severe aortic stenosis (AS). BackgroundThe prognostic impact of LVEF in severe AS remains controversial. MethodsAmong 3,815 consecutive patients with severe AS enrolled in the CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis) registry, the present study population consisted of 3,794 patients after excluding 21 patients without LVEF data. Patients were divided into 4 groups according to LVEF at index echocardiography (<50%, 50% to 59%, 60% to 69%, and ≥70%; conservative strategy: n = 388, n = 390, n = 1,025, and n = 800; initial aortic valve replacement strategy: n = 206, n = 170, n = 375, and n = 440). Echocardiographic data were site reported, and there was no echocardiography core laboratory. ResultsIn the conservative group, the cumulative 5-year incidence of the primary outcome measure (a composite of aortic valve–related death or heart failure hospitalization) was significantly higher in patients with LVEFs <50% and 50% to 59% than in those with LVEFs 60% to 69% and ≥70% (72.3%, 58.4%, 38.7%, and 35.0%, respectively, p < 0.001), whereas in the initial aortic valve replacement group, the negative effect of low LVEF was markedly attenuated (20.2%, 20.3%, 17.7%, and 12.4%, respectively, p = 0.03). After adjusting for confounders, LVEF <50% (hazard ratio: 1.82; 95% confidence interval: 1.44 to 2.28; p < 0.001) and 50% to 59% (hazard ratio: 1.77; 95% confidence interval: 1.42 to 2.20; p < 0.001) but not 60% to 69% (hazard ratio: 1.14; 95% confidence interval: 0.94 to 1.39; p = 0.17) were independently associated with poorer outcomes compared with LVEF ≥70% (reference) in the conservative group. In the initial aortic valve replacement group, the adjusted risk for the primary outcome measure was not significantly different across the 4 LVEF groups. ConclusionsThis study demonstrates that survival in patients with severe AS is impaired when LVEF is <60%, and these findings have implications for decision making with regard to the timing of surgical intervention.

Causes of Death in Patients with Severe Aortic Stenosis: An Observational study

Whether patients with severe aortic stenosis (AS) die because of AS-related causes is an important issue for the management of these patients. We used data from CURRENT AS registry, a Japanese multicenter registry, to assess the causes of death in severe AS patients and to identify the factors associated with non-cardiac mortality. We enrolled 3815 consecutive patients with a median follow-up of 1176 days; the 1449 overall deaths comprised 802 (55.3%) from cardiac and 647 (44.7%) from non-cardiac causes. Heart failure (HF) (25.7%) and sudden death (13.0%) caused the most cardiac deaths, whereas infection (13.0%) and malignancy (11.1%) were the main non-cardiac causes. According to treatment strategies, infection was the most common cause of non-cardiac death, followed by malignancy, in both the initial aortic valve replacement (AVR) cohort (N = 1197), and the conservative management cohort (N = 2618). Both non-cardiac factors (age, male, body mass index <22, diabetes, prior history of stroke, dialysis, anemia, and malignancy) and cardiac factors (atrial fibrillation, ejection fraction <68%, and the initial AVR strategy) were associated with non-cardiac death. These findings highlight the importance of close monitoring of non-cardiac comorbidities, as well as HF and sudden death, to improve the mortality rate of severe AS patients.

Impact of the left ventricular mass index on the outcomes of severe aortic stenosis

ObjectiveTo elucidate the factors associated with high left ventricular mass index (LVMI) and to test the hypothesis that high LVMI is associated with worse outcome in severe aortic stenosis (AS).MethodsWe...

Five-Year Clinical Outcome of Asymptomatic vs. Symptomatic Severe Aortic Stenosis After Aortic Valve Replacement

There is discordance regarding the effect of symptom status before aortic valve replacement (AVR) on long-term outcome after AVR in severe aortic stenosis (AS).Methods and Results:The CURRENT AS registry is a multicenter retrospective registry enrolling 3,815 consecutive patients with severe AS. Among 1,196 patients managed with the initial AVR strategy, long-term clinical outcomes were compared between the symptomatic patients (n=905), and asymptomatic patients (n=291). Median follow-up interval was 1337 days with a 91% follow-up rate at 2 years. AVR was performed in 886 patients (98%) in the symptomatic group and in 287 patients (99%) in the asymptomatic group. Symptomatic patients were older and more often had comorbidities than asymptomatic patients with similar echocardiographic AS severity. The cumulative 5-year incidences of all-cause death and heart failure (HF) hospitalization were significantly higher in symptomatic patients than in asymptomatic patients (25.6% vs. 15.4%, P=0.001, and 14.2% vs. 3.8%, P<0.001, respectively). On landmark analysis at 30 days after AVR, the differences in mortality and HF hospitalization between the 2 groups were mainly observed beyond 30 days. When managed with the initial AVR strategy, the long-term outcomes of symptomatic severe AS were worse than those of asymptomatic severe AS. Early AVR strategy might be recommended in some selected asymptomatic severe AS patients with reasonable operative risk.

Abstract 12940: Prognosis of Hemodialysis Patients With Severe Aortic Stenosis: Findings From the Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis (CURRENT AS) Registry

Background: Prognosis of hemodialysis (HD) patients with severe aortic stenosis (AS) remains unclear. Methods and Results: The CURRENT AS registry, a Japanese multicenter registry enrolled 3815 consecutive patients with severe AS. There were 1197 patients treated with the initial aortic valve replacement (AVR) strategy including surgical AVR and transcatheter aortic valve implantation and 2617 patients treated with the conservative strategy. The median follow-up duration after the index echocardiography was 1361 days, with a 90% follow-up at 2-year. HD patients accounted for 11% (405/3815 patients). The cumulative 5-year incidence of all-cause death (primary outcome measure) was significantly higher in HD patients than in non-HD patients in both the entire cohort and the initial AVR group (see Figure). Among HD patients, the initial AVR group as compared with the conservative group was associated with significantly lower cumulative 5-year incedences of all-cause death (see Figure) and sudden death (10.2% versus 31.7%, P&lt;0.001). Operative mortality rate at 30-day after AVR in HD patients was as high as 7.7% (10/131 patients). Conclusions: Being on HD indicates a grimmer prognosis in patients with severe AS, even when treated with the initial AVR strategy. The initial AVR strategy in HD patients was associated with high operative mortality risk, while it was associated with lower risk of death in long-term.