Author + information
- Received September 5, 2014
- Revision received October 27, 2014
- Accepted November 3, 2014
- Published online April 27, 2015.
- Crochan J. O’Sullivan, MD∗,†,
- Lars Englberger, MD‡,
- Nicola Hosek, MS∗,
- Dik Heg, PhD§,‖,
- Davide Cao, MD∗,
- Giulio G. Stefanini, MD∗,
- Stefan Stortecky, MD∗,
- Steffen Gloekler, MD∗,
- Ernest Spitzer, MD∗,
- David Tüller, MD†,
- Christoph Huber, MD‡,
- Thomas Pilgrim, MD∗,
- Fabien Praz, MD∗,
- Lutz Buellesfeld, MD∗,
- Ahmed A. Khattab, MD∗,
- Thierry Carrel, MD‡,
- Bernhard Meier, MD∗,
- Stephan Windecker, MD∗,§ and
- Peter Wenaweser, MD∗∗ ()
- ∗Department of Cardiology, Bern University Hospital, Bern, Switzerland
- †Department of Cardiology, Stadtspital Triemli, Zürich, Switzerland
- ‡Department of Cardiovascular Surgery, Bern University Hospital, Bern, Switzerland
- §Clinical Trials Unit, Bern University Hospital, Bern, Switzerland
- ‖Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- ↵∗Reprint requests and correspondence:
Dr. Peter Wenaweser, Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, 3010 Bern, Switzerland.
Objectives This study compared clinical outcomes and revascularization strategies among patients presenting with low ejection fraction, low-gradient (LEF-LG) severe aortic stenosis (AS) according to the assigned treatment modality.
Background The optimal treatment modality for patients with LEF-LG severe AS and concomitant coronary artery disease (CAD) requiring revascularization is unknown.
Methods Of 1,551 patients, 204 with LEF-LG severe AS (aortic valve area <1.0 cm2, ejection fraction <50%, and mean gradient <40 mm Hg) were allocated to medical therapy (MT) (n = 44), surgical aortic valve replacement (SAVR) (n = 52), or transcatheter aortic valve replacement (TAVR) (n = 108). CAD complexity was assessed using the SYNTAX score (SS) in 187 of 204 patients (92%). The primary endpoint was mortality at 1 year.
Results LEF-LG severe AS patients undergoing SAVR were more likely to undergo complete revascularization (17 of 52, 35%) compared with TAVR (8 of 108, 8%) and MT (0 of 44, 0%) patients (p < 0.001). Compared with MT, both SAVR (adjusted hazard ratio [adj HR]: 0.16; 95% confidence interval [CI]: 0.07 to 0.38; p < 0.001) and TAVR (adj HR: 0.30; 95% CI: 0.18 to 0.52; p < 0.001) improved survival at 1 year. In TAVR and SAVR patients, CAD severity was associated with higher rates of cardiovascular death (no CAD: 12.2% vs. low SS [0 to 22], 15.3% vs. high SS [>22], 31.5%; p = 0.037) at 1 year. Compared with no CAD/complete revascularization, TAVR and SAVR patients undergoing incomplete revascularization had significantly higher 1-year cardiovascular death rates (adj HR: 2.80; 95% CI: 1.07 to 7.36; p = 0.037).
Conclusions Among LEF-LG severe AS patients, SAVR and TAVR improved survival compared with MT. CAD severity was associated with worse outcomes and incomplete revascularization predicted 1-year cardiovascular mortality among TAVR and SAVR patients.
- aortic stenosis
- coronary artery disease
- surgical aortic valve replacement
- transcatheter aortic valve replacement
This work was supported in part by an unrestricted research grant from Medtronic to the University of Bern, Switzerland. Dr. Meier has received institutional educational and research support from Abbott, Cordis, Boston Scientific, and Medtronic. Dr. Windecker has received institutional research contracts from Biotronik and St. Jude; and speaker honoraria from AstraZeneca, Eli Lilly, and Abbott Vascular. Dr. Wenaweser has received an institutional research grant from Medtronic; proctoring fees from Boston Scientific; and proctoring and lecture fees from Medtronic and Edwards Lifesciences. Dr. Stefanini has received speaker fees from Abbott Vascular, AstraZeneca, Biosensors, and Biotronik. Dr. Spitzer is the recipient of a Research Fellowship of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology and a Research Grant of the Spanish Society of Cardiology. Dr. Huber has received proctor and lecturing fees from Symetis and Edwards Lifesciences; and is a consultant for Medtronic. Dr. Buellesfeld is a consultant for Medtronic, Edwards Lifesciences, and Abbott Vascular. Dr. Khattab is a proctor for Medtronic and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. O'Sullivan and Englberger contributed equally to this manuscript.
- Received September 5, 2014.
- Revision received October 27, 2014.
- Accepted November 3, 2014.
- American College of Cardiology Foundation