JACC: Cardiovascular Interventions
Structural: Focus on TAVR
Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Severe Aortic Stenosis
Tomohiko Taniguchi, Takeshi Morimoto, Hiroki Shiomi, Kenji Ando, Norio Kanamori, Koichiro Murata, Takeshi Kitai, Kazushige Kadota, Chisato Izumi, Kenji Nakatsuma, Tomoki Sasa, Hirotoshi Watanabe, Yasuhide Kuwabara, Takeru Makiyama, Koh Ono, Satoshi Shizuta, Takao Kato, Naritatsu Saito, Kenji Minatoya, Takeshi Kimura, on behalf of the CURRENT AS Registry Investigators, Takeshi Kimura, Tomohiko Taniguchi, Hiroki Shiomi, Naritatsu Saito, Masao Imai, Junichi Tazaki, Toshiaki Toyota, Hirooki Higami, Tetsuma Kawaji, Kenji Ando, Shinichi Shirai, Kengo Kourai, Takeshi Arita, Shiro Miura, Kyohei Yamaji, Takeshi Aoyama, Norio Kanamori, Tomoya Onodera, Koichiro Murata, Yutaka Furukawa, Takeshi Kitai, Kitae Kim, Kazushige Kadota, Yuichi Kawase, Keiichiro Iwasaki, Hiroshi Miyawaki, Ayumi Misao, Akimune Kuwayama, Masanobu Ohya, Takenobu Shimada, Hidewo Amano, Yoshihisa Nakagawa, Chisato Izumi, Makoto Miyake, Masashi Amano, Yusuke Takahashi, Yusuke Yoshikawa, Shunsuke Nishimura, Maiko Kuroda, Manabu Shirotani, Hirokazu Mitsuoka, Shinji Miki, Tetsu Mizoguchi, Masashi Kato, Takafumi Yokomatsu, Akihiro Kushiyama, Hidenori Yaku, Toshimitsu Watanabe, Shunichi Miyazaki, Yutaka Hirano, Mitsuo Matsuda, Shintaro Matsuda, Sachiko Sugioka, Tsukasa Inada, Kazuya Nagao, Naoki Takahashi, Kohei Fukuchi, Tomoyuki Murakami, Hiroshi Mabuchi, Teruki Takeda, Tomoko Sakaguchi, Keiko Maeda, Masayuki Yamaji, Motoyoshi Maenaka, Yutaka Tadano, Hiroki Sakamoto, Yasuyo Takeuchi, Makoto Motooka, Ryusuke Nishikawa, Hiroshi Eizawa, Keiichiro Yamane, Mitsunori Kawato, Minako Kinoshita, Kenji Aida, Takashi Tamura, Mamoru Toyofuku, Kousuke Takahashi, Euihong Ko, Masaharu Akao, Mitsuru Ishii, Nobutoyo Masunaga, Hisashi Ogawa, Moritake Iguchi, Takashi Unoki, Kensuke Takabayashi, Yasuhiro Hamatani, Yugo Yamashita, Moriaki Inoko, Eri Minamino-Muta, Takao Kato, Yoshihiro Himura, Tomoyuki Ikeda, Katsuhisa Ishii, Akihiro Komasa, Yukihito Sato, Kozo Hotta, Shuhei Tsuji, Yuji Hiraoka, Nobuya Higashitani, Ichiro Kouchi, Yoshihiro Kato, Shigeru Ikeguchi, Yasutaka Inuzuka, Soji Nishio, Jyunya Seki, Eiji Shinoda, Miho Yamada, Akira Kawamoto, Chiyo Maeda, Takashi Konishi, Toshikazu Jinnai, Kouji Sogabe, Michiya Tachiiri, Yukiko Matsumura, Chihiro Ota, Shoji Kitaguchi, Yuko Morikami, Ryuzo Sakata, Kenji Minakata, Kenji Minatoya, Michiya Hanyu, Fumio Yamazaki, Tadaaki Koyama, Tatsuhiko Komiya, Kazuo Yamanaka, Noboru Nishiwaki, Hiroyuki Nakajima, Motoaki Ohnaka, Hiroaki Osada, Katsuaki Meshii, Toshihiko Saga, Masahiko Onoe, Shogo Nakayama, Genichi Sakaguchi, Atsushi Iwakura, Kotaro Shiraga, Koji Ueyama, Keiichi Fujiwara, Atsushi Fukumoto, Masaki Park, Junichiro Nishizawa and Mitsuru Kitano
Table 1
Table 1
Baseline Clinical and Echocardiographic Characteristics According to the Baseline Left Ventricular Ejection Fraction Categories in the Entire Cohort
| LVEF <50% (n = 594) | LVEF 50%–59% (n = 560) | LVEF 60%–69% (n = 1,400) | LVEF ≥70% (n = 1,240) | p Value | |
|---|---|---|---|---|---|
| Clinical characteristics | |||||
| Age, yrs∗ | 78.4 ± 9.4 | 78.7 ± 10.0 | 78.0 ± 9.7 | 76.7 ± 9.8 | <0.001 |
| Age ≥80 yrs | 283 (48) | 279 (50) | 638 (46) | 514 (41) | 0.004 |
| Male∗ | 303 (51) | 243 (43) | 522 (37) | 370 (30) | <0.001 |
| BMI, kg/m2 | 21.1 ± 3.8 | 21.5 ± 3.8 | 21.9 ± 3.9 | 22.1 ± 3.7 | <0.001 |
| BMI <22 kg/m2∗ | 399 (67) | 355 (63) | 835 (60) | 722 (58) | 0.001 |
| BSA, m2 | 1.47 ± 0.18 | 1.45 ± 0.19 | 1.46 ± 0.19 | 1.46 ± 0.18 | 0.58 |
| Hypertension∗ | 421 (71) | 379 (68) | 1,009 (72) | 847 (68) | 0.10 |
| Current smoking∗ | 34 (6) | 27 (5) | 76 (5) | 58 (5) | 0.73 |
| History of smoking | 159 (27) | 135 (24) | 305 (22) | 228 (18) | <0.001 |
| Dyslipidemia | 191 (32) | 164 (29) | 469 (34) | 498 (40) | <0.001 |
| On statin therapy | 137 (23) | 108 (19) | 345 (25) | 377 (30) | <0.001 |
| Diabetes mellitus | 176 (30) | 130 (23) | 333 (24) | 256 (21) | <0.001 |
| On insulin therapy∗ | 37 (6) | 32 (6) | 66 (5) | 53 (4) | 0.25 |
| Prior myocardial infarction∗ | 140 (24) | 63 (11) | 74 (5) | 42 (3) | <0.001 |
| Coronary artery disease∗ | 290 (49) | 189 (34) | 361 (26) | 295 (24) | <0.001 |
| Prior PCI | 137 (23) | 81 (14) | 168 (12) | 115 (9) | <0.001 |
| Prior CABG | 67 (11) | 40 (7) | 50 (4) | 40 (3) | <0.001 |
| Prior open heart surgery | 83 (14) | 61 (11) | 101 (7) | 69 (6) | <0.001 |
| Prior symptomatic stroke∗ | 87 (15) | 73 (13) | 228 (16) | 112 (9) | <0.001 |
| Atrial fibrillation or flutter∗ | 146 (25) | 158 (28) | 307 (22) | 212 (17) | <0.001 |
| Aortic/peripheral vascular disease∗ | 65 (11) | 46 (8) | 105 (8) | 65 (5) | <0.001 |
| Serum creatinine, mg/dl∗ | 1.1 (0.8–2.1) | 1.0 (0.7–1.5) | 0.9 (0.7–1.2) | 0.8 (0.7–1.0) | <0.001 |
| Creatinine >2 mg/dl | 151 (25) | 108 (19) | 198 (14) | 100 (8) | <0.001 |
| Hemodialysis∗ | 105 (18) | 83 (15) | 149 (11) | 67 (5) | <0.001 |
| Anemia∗† | 380 (64) | 341 (61) | 775 (55) | 611 (49) | <0.001 |
| Liver cirrhosis (Child-Pugh B/C)∗ | 6 (1) | 2 (0.4) | 19 (1) | 10 (1) | 0.19 |
| Malignancy | 85 (14) | 69 (12) | 192 (14) | 170 (14) | 0.79 |
| Malignancy currently under treatment∗ | 21 (4) | 17 (3) | 63 (5) | 48 (4) | 0.45 |
| Chest wall irradiation | 6 (1) | 3 (1) | 9 (1) | 7 (1) | 0.70 |
| Immunosuppressive therapy | 24 (4) | 18 (3) | 38 (3) | 50 (4) | 0.23 |
| Chronic lung disease | 64 (11) | 67 (12) | 137 (10) | 130 (10) | 0.55 |
| Chronic lung disease (moderate or severe)∗ | 23 (4) | 18 (3) | 37 (3) | 33 (3) | 0.43 |
| Logistic EuroSCORE, % | 19.3 (10.9–31.7) | 10.9 (6.2–18.0) | 9.0 (5.5–14.4) | 7.9 (4.9–12.8) | <0.001 |
| EuroSCORE II, % | 5.7 (3.4–10.3) | 3.1 (1.8–5.6) | 2.7 (1.6–4.1) | 2.4 (1.3–3.7) | <0.001 |
| STS PROM score, % | 5.8 (3.3–10.4) | 4.6 (2.6–7.9) | 3.7 (2.2–6.0) | 3.0 (2.0–4.9) | <0.001 |
| Symptom related to AS | 452 (76) | 347 (62) | 628 (45) | 562 (45) | <0.001 |
| Chest pain | 70 | 71 | 146 | 204 | |
| Syncope | 22 | 38 | 80 | 56 | |
| Heart failure | 431 | 300 | 477 | 384 | |
| HF hospitalization at index echocardiography∗ | 280 (47) | 168 (30) | 195 (14) | 141 (11) | <0.001 |
| Etiology of aortic stenosis | |||||
| Degenerative | 549 (92) | 503 (90) | 1,251 (89) | 1,057 (85) | 0.001 |
| Congenital (unicuspid, bicuspid, or quadricuspid) | 30 (5) | 34 (6) | 79 (6) | 114 (9) | |
| Rheumatic | 9 (2) | 20 (4) | 61 (4) | 59 (5) | |
| Infective endocarditis | 1 (0.2) | 2 (0.4) | 2 (0.1) | 2 (0.2) | |
| Other | 5 (1) | 1 (0.2) | 7 (0.5) | 8 (0.7) | |
| Echocardiographic variables | |||||
| Vmax, m/s | 3.78 ± 0.99 | 4.13 ± 0.96 | 4.11 ± 0.87 | 4.33 ± 0.86 | <0.001 |
| Vmax ≥5 m/s | 81 (14) | 99 (18) | 245 (18) | 268 (22) | <0.001 |
| Vmax ≥4 m/s∗ | 255 (43) | 316 (56) | 769 (55) | 829 (67) | <0.001 |
| Peak aortic PG, mm Hg | 61 ± 31 | 72 ± 34 | 71 ± 30 | 78 ± 31 | <0.001 |
| Mean aortic PG, mm Hg | 35 ± 19 | 40 ± 20 | 40 ± 19 | 45 ± 20 | <0.001 |
| AVA (continuity equation), cm2 | 0.68 ± 0.20 | 0.70 ± 0.19 | 0.73 ± 0.17 | 0.74 ± 0.18 | <0.001 |
| Indexed AVA, cm2/m2 | 0.47 ± 0.14 | 0.49 ± 0.13 | 0.51 ± 0.13 | 0.51 ± 0.12 | <0.001 |
| LV end-diastolic diameter, mm | 52.7 ± 7.8 | 46.9 ± 6.6 | 44.5 ± 5.8 | 43.9 ± 5.9 | <0.001 |
| LV end-systolic diameter, mm | 42.3 ± 8.2 | 33.0 ± 5.7 | 28.6 ± 4.5 | 25.1 ± 4.4 | <0.001 |
| LVEF, % | 38.1 ± 8.6 | 55.0 ± 2.8 | 65.0 ± 2.8 | 75.6 ± 4.9 | <0.001 |
| IVST in diastole, mm | 10.9 ± 2.4 | 11.6 ± 2.2 | 11.2 ± 2.2 | 11.6 ± 2.3 | <0.001 |
| PWT in diastole, mm | 10.5 ± 2.2 | 11.1 ± 2.2 | 10.9 ± 1.9 | 11.2 ± 2.0 | <0.001 |
| Any combined valvular disease (moderate or severe)∗ | 303 (51) | 278 (50) | 543 (39) | 428 (35) | <0.001 |
| Moderate or severe AR | 135 (23) | 138 (25) | 277 (20) | 239 (19) | 0.03 |
| Moderate or severe MS | 14 (2) | 22 (4) | 54 (4) | 43 (3) | 0.37 |
| Moderate or severe MR | 211 (36) | 152 (27) | 240 (17) | 155 (13) | <0.001 |
| Moderate or severe TR | 127 (21) | 101 (18) | 223 (16) | 175 (14) | <0.001 |
| TR PG ≥40 mm Hg∗ | 142 (24) | 105 (19) | 176 (13) | 181 (15) | <0.001 |
| Treatment strategy | |||||
| Initial AVR | 206 (35) | 170 (30) | 375 (27) | 440 (35) | <0.001 |
| Conservative | 388 (65) | 390 (70) | 1,025 (73) | 800 (65) | |
Values are mean ± SD or n (%).
AR = aortic regurgitation; AVA = aortic valve area; AVR = aortic valve replacement; BMI = body mass index; BSA = body surface area; CABG = coronary artery bypass grafting; EuroSCORE = European System for Cardiac Operative Risk Evaluation; HF = heart failure; IVST = interventricular septal thickness; LV = left ventricular; LVEF = left ventricular ejection fraction; MR = mitral regurgitation; MS = mitral stenosis; PCI = percutaneous coronary intervention; PG = pressure gradient; PROM = Predicted Risk of Mortality; PWT = posterior wall thickness; STS = Society of Thoracic Surgeons; TR = tricuspid regurgitation; Vmax = peak aortic jet velocity.
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