Transcatheter Aortic Valve Replacement versus Medical Management among Patients with Aortic Stenosis and Left Ventricular Systolic Dysfunction

ABSTRACT

Background: There is limited evidence regarding outcomes of patients with severe aortic stenosis (AS) and concomitant left ventricular systolic dysfunction (LVSD). We evaluated mortality in patients with severe AS and LVSD undergoing transcatheter aortic valve replacement (TAVR) compared with a matched medically managed cohort.

Methods: We studied 206 patients who underwent TAVR at Duke University and had a transthoracic echocardiogram within 6 months prior to the procedure and a matched medically managed historical cohort (n = 206). All TAVR patients were matched 1:1 by AS resting mean gradient and/or peak velocity, age, left ventricular ejection fraction (LVEF) and EuroSCORE. We used Cox multivariable modeling to assess the relationship between TAVR and all-cause mortality. Two survival analyses were completed to evaluate mortality—first in patients with LVEF≤ 35% and then with LVEF≤ 35% versus 36–50%.

Results: The median age of patients was 82 (IQR 76–86). Patients who underwent TAVR were more likely to be male, have a history of ischemic heart disease, renal insufficiency, heart failure and coronary artery bypass graft (CABG) (all p < 0.05). TAVR was associated with mortality reduction compared with medical management (HR 0.31, 95%CI 0.21–0.45, p < 0.0001), which persisted after multivariable adjustment (HR 0.26, 95%CI 0.18–0.39, p < 0.0001). After adjustment, TAVR provided a larger estimated decrease in mortality risk in patients with LVEF> 35% (HR 0.23, 95%CI 0.15–0.35), than in patients with LVEF≤ 35% (HR 0.60, 95%CI 0.23–1.52, p-interaction = 0.0605).

Conclusion: Compared with medical management, TAVR is associated with longer survival in all patients, including those with LVSD. TAVR should be explored further as a therapeutic option in this patient population.

KEYWORDS:

• Clinical cardiology
• echocardiography
• interventional cardiology
• medical devices

Disclosure statements

Lowenstern: received funding through NIH T-32 training grant #5 T32 HL069749-14; Vora: received funding through NIH T-32 training grant #5 T32 HL7101-38 grant; Dunning: none; Schulte: none; Vemulapalli: American College of Cardiology, Society of Thoracic Surgeons, Patient Centered Outcomes Research Institute, Abbott Vascular; receiving consulting fees from Novella and Premiere; Hughes: No relevant disclosures; Velazquez: salary support through a NHLBI research grant; research grants from Abbott Laboratories, Evalve, and Ikaria; receiving consulting fees from Boehringer Ingelheim, Gilead, and Novartis, Harrison: no relevant disclosures; Samad: salary support through a National Heart, Lung, and Blood Institute (NHLBI) research grant, American Society of Echocardiography research grant, Boston Scientific-Duke Strategic Alliance for Research, sub-award from Duke O’Brien Kidney Research Core Centers Program NIH 1P30DK096493-01.

Additional information

Funding

This study was funded by a grant from Boston Scientific-Duke Strategic Alliance for Research to ZS. Boston Scientific was not involved in the study design, the collection, analysis and interpretation of data, the writing of the report, or in the decision to submit the article for publication.