Short and Mid-term Outcome of Surgical Intervention for Low-gradient Aortic Stenosis Patients with Impaired Left Ventricular Function_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

FANGQin ,  GUTian-xiang , LIULu , LIUBo , LUChun-mao , YUPeng

Department of Cardiac Surgery, the First Affiliated Hospital of China Medical University, Shenyang 110001, P. R. China;

Corresponding author：

GUTian-xiang, Email: cmugtx@sina.com

Keywords：

Aortic stenosis; Pressure gradient; Left ventricular function

DOI：

10.7507/1007-4848.20160003

Video：

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Objectives To investigate simple assess method of the degree of low transvalvular gradient aortic stenosis patients with impaired left ventricular function and to investigate aortic valve replacement indications, short and mid-term outcome of this kind of patients. Methods We retrospectively analyzed the clinical data of 21 low-gradient patients with impaired left ventricular function in our hospital from January 2011 through May 2014. There were 15 males and 6 females aged 41-66 (54.6± 10.7) years with mean aortic transvalvular gradient less than 40 mm Hg and left ventricular ejection fraction (LVEF) less than 50%. Results In response to dobutamine echocardiography stress test, 20 patients underwent aortic valve replacement. The result of intraoperative pathology showed 11 patients were with bicuspid aortic valve malformation, 4 patients with degenerative changes, 4 patients with rheumatic disease. During the same period, 3 patients underwent atrial fibrillation ablation, 1 patient with ascending aorta replacement, 2 patients with coronary artery bypass grafting, 1 patient with mitral valvuloplasty. One patient died of multiple organ failure on the fourth day after operation. The remaining patients recovered. The patients were followed up for 3 to 37 months after operation. Heart function of majority improved to gradeⅠorⅡin 3 months after surgery. The result of echocardiogram showed prosthetic valve function was good and LVEF increased (preoperative 35.7%± 8.2% vs. postoperative 49.4%± 7.2%). One patient suffered sudden death of unknown cause in the 11th months after operation. Conclusions For patients whose dobutamine echocardiography stress test displayed with true severe aortic stenosis and left ventricular contractile reserve capacity, after aortic valve replacement and relief of the obstruction, the left ventricular afterload decreases significantly, the left ventricular function also improves, LVEF and the quality of life improve significantly after operation.

Citation： FANGQin, GUTian-xiang, LIULu, LIUBo, LUChun-mao, YUPeng. Short and Mid-term Outcome of Surgical Intervention for Low-gradient Aortic Stenosis Patients with Impaired Left Ventricular Function. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2016, 23(1): 12-16. doi: 10.7507/1007-4848.20160003 Copy

1.	Khandhar S, Varadarajan P, Turk R, et al. Survival benefit of aortic valve replacement in patients with severe aortic regurgitation and pulmonary hypertension. Ann Thorac Surg, 2009, 88(3): 752-756.
2.	Rassi AN, Pibarot P, Elmariah S, et al. Left ventricular remodelling in aortic stenosis. Can J Cardiol, 2014, 30(9): 1004-1011.
3.	Chin CW, Khaw HJ, Luo E, et al. Echocardiography underestimates stroke volume and aortic valve area: implications for patients with small-arealow-gradient aortic stenosis. Can J Cardiol, 2014, 30(9): 1064-1072.
4.	Biner S, Birati EY, Topilsky Y, et al. Outcome of transcatheter aortic valve implantation in patients with low-gradient severe aortic stenosis and preserved left ventricular ejection fraction. Am J Cardiol, 2014, 113(2): 348-354.
5.	Clavel MA, Fuchs C, Burwash IG, et al. Predictors of outcomes in low-flow, low-gradient aortic stenosis: results of the multicenter TOPAS Study. Circulation, 2008, 118(14 Suppl): S234-242.
6.	Maes F, Boulif J, Pié rard S, et al. Natural history of paradoxical low-gradient severe aortic stenosis.Circ Cardiovasc Imaging, 2014, 7(4): 714-722.
7.	Tandon A, Grayburn PA. Imaging of low-gradient severe aortic stenosis. JACC Cardiovasc Imaging, 2013, 6(2): 184-195.
8.	Ben-Dor I, Maluenda G, Iyasu GD, et al. Comparison of outcome of higher versus lower transvalvular gradients in patients with severe aortic stenosis andlow ( < 40%) left ventricular ejection fraction. Am J Cardiol, 2012, 109(7): 1031-1037.
9.	Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guide-line for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg, 2014, 148(1): e1-e132.
10.	Tarantini G, Covolo E, Razzolini R, et al. Valve replacement for severe aortic stenosis with low transvalvular gradient and left ventricular ejection fraction exceeding 0.50. Ann Thorac Surg, 2011, 91(6): 1808-1815.
11.	Rossi A, Nistri S, Cioffi G, et al. Severe aortic valve stenosis with normal left ventricular function and low vs. high pressure gradient: different hemodynamic profiles but similar clinical presentation, comorbidity and outcome. Int J Cardiol, 2013, 167(5): 2326-2328.
12.	Grupper A, Beigel R, Maor E, et al. Survival after intervention in patients with low gradient severe aortic stenosis and preserved left ventricular function. J Thorac Cardiovasc Surg, 2014, 148(6): 2823-2827.
13.	Pereira JJ, Lauer MS, Bashir M, et al. Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction. J Am Coll Cardiol, 2002, 39(8): 1356-1363.
14.	Eleid MF, Pellikka PA. Potential impact of concomitant valvular lesions and coronary artery bypass surgery on outcome in low-gradient severe aortic stenosis with preserved ejection fraction. J Am Coll Cardiol, 2013, 61(17): 1832-1833.
15.	Antonini-Canterin F, Pavan D, Burelli C, et al. Validation of the ejection fraction-velocity ratio: a new simplified "function-corrected" index for assessing aortic stenosis severity. Am J Cardiol, 2000, 86(4): 427-433.
16.	Cattaneo P, Marchetti P, Baravelli M, et al. Ejection fraction-velocity ratio for the assessment of aortic bioprosthetic valves in patients with systolic dysfunction. Can J Cardiol, 2009, 25(3): e78-e81.
17.	Shah BN, Chahal NS, Senior R. Low-flow low-gradient aortic stenosis in patients with low ejection fraction: but is the flow truly low? Int J Cardiol, 2013, 168(5): 4999-5001.
18.	Lauten J, Rost C, Breithardt OA, et al. Invasive hemodynamic charac-teristics of low gradient severe aortic stenosis despite preserved ejection fraction. J Am Coll Cardiol, 2013, 61(17): 1799-1808.
19.	Vinco G, Bergamini C, Pighi M, et al. Meta-analysis of the outcome of patients with low gradient severe aortic stenosis and preserved left ventricular ejection fraction. Int J Cardiol, 2013, 168(5): 5076-5078.
20.	Clavel MA, Ennezat PV, Maré chaux S, et al. Stress echocardiography to assess stenosis severity and predict outcome in patients with paradoxical low-flow, low-gradient aortic stenosis and preserved LVEF. JACC Cardiovasc Imaging, 2013, 6(2): 175-183.
21.	Tribouilloy C, Lé vy F, Rusinaru D, et al. Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography. J Am Coll Cardiol, 2009, 53(20): 1865-1873.
22.	Clavel MA, Dumesnil JG, Capoulade R, et al. Outcome of patients with aortic stenosis, small valve area, and low-flow, low-gradient despite preserved left ventricular ejection fraction. J Am Coll Cardiol, 2012, 60(14): 1259-1267.
23.	Halkos ME, Chen EP, Sarin EL, et al. Aortic valve replacement for aortic stenosis in patients with left ventricular dysfunction. Ann Thorac Surg, 2009, 88(3): 746-751.
24.	Kulik A, Burwash IG, Kapila V, et al. Long-term outcomes after valve replacement for low-gradient aortic stenosis: impact of prosthesis-patient mismatch. Circulation, 2006, 114(1 Suppl): I553-I558.

1. Khandhar S, Varadarajan P, Turk R, et al. Survival benefit of aortic valve replacement in patients with severe aortic regurgitation and pulmonary hypertension. Ann Thorac Surg, 2009, 88(3): 752-756.
2. Rassi AN, Pibarot P, Elmariah S, et al. Left ventricular remodelling in aortic stenosis. Can J Cardiol, 2014, 30(9): 1004-1011.
3. Chin CW, Khaw HJ, Luo E, et al. Echocardiography underestimates stroke volume and aortic valve area: implications for patients with small-arealow-gradient aortic stenosis. Can J Cardiol, 2014, 30(9): 1064-1072.
4. Biner S, Birati EY, Topilsky Y, et al. Outcome of transcatheter aortic valve implantation in patients with low-gradient severe aortic stenosis and preserved left ventricular ejection fraction. Am J Cardiol, 2014, 113(2): 348-354.
5. Clavel MA, Fuchs C, Burwash IG, et al. Predictors of outcomes in low-flow, low-gradient aortic stenosis: results of the multicenter TOPAS Study. Circulation, 2008, 118(14 Suppl): S234-242.
6. Maes F, Boulif J, Pié rard S, et al. Natural history of paradoxical low-gradient severe aortic stenosis.Circ Cardiovasc Imaging, 2014, 7(4): 714-722.
7. Tandon A, Grayburn PA. Imaging of low-gradient severe aortic stenosis. JACC Cardiovasc Imaging, 2013, 6(2): 184-195.
8. Ben-Dor I, Maluenda G, Iyasu GD, et al. Comparison of outcome of higher versus lower transvalvular gradients in patients with severe aortic stenosis andlow ( < 40%) left ventricular ejection fraction. Am J Cardiol, 2012, 109(7): 1031-1037.
9. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guide-line for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg, 2014, 148(1): e1-e132.
10. Tarantini G, Covolo E, Razzolini R, et al. Valve replacement for severe aortic stenosis with low transvalvular gradient and left ventricular ejection fraction exceeding 0.50. Ann Thorac Surg, 2011, 91(6): 1808-1815.
11. Rossi A, Nistri S, Cioffi G, et al. Severe aortic valve stenosis with normal left ventricular function and low vs. high pressure gradient: different hemodynamic profiles but similar clinical presentation, comorbidity and outcome. Int J Cardiol, 2013, 167(5): 2326-2328.
12. Grupper A, Beigel R, Maor E, et al. Survival after intervention in patients with low gradient severe aortic stenosis and preserved left ventricular function. J Thorac Cardiovasc Surg, 2014, 148(6): 2823-2827.
13. Pereira JJ, Lauer MS, Bashir M, et al. Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction. J Am Coll Cardiol, 2002, 39(8): 1356-1363.
14. Eleid MF, Pellikka PA. Potential impact of concomitant valvular lesions and coronary artery bypass surgery on outcome in low-gradient severe aortic stenosis with preserved ejection fraction. J Am Coll Cardiol, 2013, 61(17): 1832-1833.
15. Antonini-Canterin F, Pavan D, Burelli C, et al. Validation of the ejection fraction-velocity ratio: a new simplified "function-corrected" index for assessing aortic stenosis severity. Am J Cardiol, 2000, 86(4): 427-433.
16. Cattaneo P, Marchetti P, Baravelli M, et al. Ejection fraction-velocity ratio for the assessment of aortic bioprosthetic valves in patients with systolic dysfunction. Can J Cardiol, 2009, 25(3): e78-e81.
17. Shah BN, Chahal NS, Senior R. Low-flow low-gradient aortic stenosis in patients with low ejection fraction: but is the flow truly low? Int J Cardiol, 2013, 168(5): 4999-5001.
18. Lauten J, Rost C, Breithardt OA, et al. Invasive hemodynamic charac-teristics of low gradient severe aortic stenosis despite preserved ejection fraction. J Am Coll Cardiol, 2013, 61(17): 1799-1808.
19. Vinco G, Bergamini C, Pighi M, et al. Meta-analysis of the outcome of patients with low gradient severe aortic stenosis and preserved left ventricular ejection fraction. Int J Cardiol, 2013, 168(5): 5076-5078.
20. Clavel MA, Ennezat PV, Maré chaux S, et al. Stress echocardiography to assess stenosis severity and predict outcome in patients with paradoxical low-flow, low-gradient aortic stenosis and preserved LVEF. JACC Cardiovasc Imaging, 2013, 6(2): 175-183.
21. Tribouilloy C, Lé vy F, Rusinaru D, et al. Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography. J Am Coll Cardiol, 2009, 53(20): 1865-1873.
22. Clavel MA, Dumesnil JG, Capoulade R, et al. Outcome of patients with aortic stenosis, small valve area, and low-flow, low-gradient despite preserved left ventricular ejection fraction. J Am Coll Cardiol, 2012, 60(14): 1259-1267.
23. Halkos ME, Chen EP, Sarin EL, et al. Aortic valve replacement for aortic stenosis in patients with left ventricular dysfunction. Ann Thorac Surg, 2009, 88(3): 746-751.
24. Kulik A, Burwash IG, Kapila V, et al. Long-term outcomes after valve replacement for low-gradient aortic stenosis: impact of prosthesis-patient mismatch. Circulation, 2006, 114(1 Suppl): I553-I558.

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Short and Mid-term Outcome of Surgical Intervention for Low-gradient Aortic Stenosis Patients with Impaired Left Ventricular Function

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