How Stable Are Patients with Moderate Aortic Stenosis and Left Ventricular Dysfunction?

Authors: WJ., J Am Coll Cardiol 2017 May 16; 69:2393

A high rate of adverse events prompts the question of whether earlier intervention would improve outcomes.

The authors of this international, four-site study examined longitudinal outcomes data on 305 patients (mean age, 73; 75% men) who were identified on baseline echocardiograms with moderate aortic stenosis (AS; defined by aortic valve area [AVA] >1.0 and <1.5 cm²) and left ventricular (LV) dysfunction (ejection fraction, <50%).

Coronary artery disease was present in 72% of patients. On echocardiography, the mean ejection fraction was 38%, mean AVA was 1.24 cm², and mean transaortic gradient was 15 mm Hg. Dobutamine stress echocardiography was used in 11% of patients to exclude severe AS.

At 4 years of follow-up, 61% had a clinical event included in the primary composite endpoint: death (36%), heart-failure hospitalization (27%), or aortic valve replacement by surgery or transcatheter (24%). In multivariate analysis, baseline New York Heart Association class III or IV, higher peak gradient, and male sex were the main predictors of the primary endpoint.

This observational study demonstrates that patients with moderate AS and LV dysfunction have a high rate of clinical events in short-term follow-up. A randomized trial to test the hypothesis that transcatheter aortic-valve replacement in such patients can improve clinical outcome was recently initiated (NCT2661451).  Caveats include the potential for measurement errors, the lack of indexing AVA for body size, inclusion of both symptomatic and asymptomatic patients, the low rate of dobutamine stress echocardiography, and the lack of optimal heart failure therapy in some patients. Nonetheless, the combination of moderate AS and LV dysfunction should be considered a warning sign for clinicians.