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Clinical Outcomes Of Patients With Low-flow, Low-gradient Severe Aortic Stenosis According To Treatment Modality
Crochan J. O'Sullivan, Lars Englberger, Stefan Stortecky, Christoph Huber, Nicola Hosek, Ahmed Khattab, Lutz Buellesfeld, Thomas Pilgrim, Bernhard Meier, Stephan Windecker, Peter Wenaweser.
Bern University Hospital, Bern, Switzerland.

OBJECTIVE: We aimed to compare clinical outcomes among patients presenting with “classical” low-flow, low-gradient severe aortic stenosis according to the assigned treatment modality.
METHODS: Between April 2005 and December 2012, 210 patients with low-flow, low-gradient severe AS (indexed aortic valve area [AVA] ≤0.6cm2.m-2, left ventricular ejection fraction [LVEF] <50% and mean gradient (MG) <40mmHg) underwent treatment allocation to either medical therapy (MT) (n=47) surgical aortic valve replacement (SAVR) (n=52) or transcatheter aortic valve implantation (TAVI) (n=111). Pre-procedural non-invasive and invasive hemodynamic indices, coronary artery disease (CAD) complexity and procedural characteristics were compared between groups. Primary end-point was all-cause mortality at 1-year.
RESULTS: Baseline characteristics were similar between patients allocated to MT and TAVI, whereas SAVR patients were younger (MT 82.47±5.03 vs SAVR 78.43±54.10 vs TAVI 82.04 ±5.08 years, p<0.0001) and lower risk (STS score MT 10.82±7.25 vs SAVR 4.85±2.95 vs TAVI 7.88±4.80 %, p<0.001) . CAD complexity was significantly greater among MT patients (SYNTAX score MT 29.18±17.89 vs SAVR 20.38±12.54 vs TAVI 21.58±14.09, p= 0.036). Pre-procedural AVA (MT 0.69±022, SAVR 0.73±0.23, TAVI 0.74±0.21cm2, p=0.40) and MG (MT 25.23±9.33 vs SAVR 29.26±9.54 vs TAVI 28.54±10.30 mmHg, p=0.09) were similar between groups, but patients undergoing SAVR had a higher baseline LVEF (MT 30.28±9.72 vs SAVR 38.90±11.94 vs TAVI 34.35±11.32%, p=0.001) and lower prevalence of moderate/severe mitral regurgitation (MT 52.3% vs SAVR 30.0% vs TAVI 52.8%, p=0.02). SAVR patients also had lower pulmonary artery systolic pressures (MT: 59.71±15.29 vs SAVR 50.63±16.15 vs TAVI 58.17±14.72 mmHg, p=0.023) on pre-procedural right heart catheterization. Contractile reserve was present in 68.8% of patients undergoing dobutamine stress echocardiography. At 12-months, the primary endpoint was significantly lower among both SAVR (13.5% vs 57.4%, HR 0.17, 95% confidence interval [CI] 0.076-0.40, p<0.001) and TAVI (20.7% vs 57.4%, HR 0.28, 95% CI 0.16-0.49, p<0.001) as compared with MT patients. No significant differences in the primary endpoint were observed between SAVR and TAVI patients (p=0.27).
CONCLUSIONS: Among patients with low-flow, low-gradient severe AS, SAVR and TAVI improved survival compared with MT. Clinical outcomes of TAVI and SAVR appeared similar among appropriately selected patients with low-flow, low-gradient severe AS.

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