Long-term predictors of mortality and functional recovery after aortic valve replacement for severe aortic stenosis with left ventricular dysfunction.

INTRODUCTION AND OBJECTIVES: At present, surgery is the only recommended effective treatment for severe aortic stenosis. However, the surgical risk is increased when left ventricular dysfunction is present. The aim of this study was to identify predictors of postoperative and long-term mortality and functional improvement after valve replacement in patients with severe aortic stenosis and left ventricular dysfunction. METHODS: Between 1996 and 2008, 635 consecutive patients with severe aortic stenosis underwent surgery. Early postoperative mortality in the 82 with an ejection fraction <40% was 19.5%. The following independent predictors of early postoperative mortality were identified: female sex (odds ratio [OR]=2.60; 95% confidence interval [CI], 2.20-89.0; P=.004), mild mitral regurgitation (OR=2.38; 95% CI, 1.40-80.0; P=.020) and coronary artery disease (OR=2.09; 95% CI, 1.26-51.0; P=.027). RESULTS: During the mean follow-up period of 42.59+/-40.83 months, overall mortality was 18.8% and cardiovascular mortality was 11.3%. The only factor associated with increased mortality during follow-up was a low postoperative cardiac output (OR=4.40; 95% CI, 1.20-15.5; P=.02). In total, 70.5% showed early improvement in ventricular function, the predictors of which were: no improvement following a previous myocardial infarction (P=.04), no revascularized coronary lesions (P=.04), and a low aortic valve pressure gradient (P=.02). Functional class improved significantly during follow-up in 93.4% of patients. CONCLUSIONS: Despite considerable early postoperative mortality in patients with aortic stenosis and left ventricular dysfunction, over the long term there was evidence of better survival coupled to improved ventricular function and functional class.

Predictores de mortalidad y recuperación funcional a largo plazo en el reemplazo valvular por estenosis aórtica severa con disfunción ventricular / Long-term predictors of mortality and functional recovery after aortic valve replacement for severe aortic stenosis with left ventricular dysfunction

Introducción y objetivos. El tratamiento quirúrgico de la estenosis aórtica severa es el único efectivo recomendado actualmente para esta patología, pero el riesgo quirúrgico aumenta con la disfunción ventricular izquierda. Nuestro objetivo fue identificar predictores de mortalidad y mejoría funcional en el postoperatorio y a largo plazo tras reemplazo valvular en pacientes con estenosis aórtica y disfunción ventricular severa. Métodos. Entre 1996 y 2008, 635 pacientes con estenosis aórtica severa fueron intervenidos, 82 con fracción de eyección < 40%, con mortalidad postoperatoria precoz del 19,5%. Identificamos como predictores independientes de mortalidad postoperatoria precoz el sexo femenino (OR = 2,60; IC del 95%, 2,20-89; p = 0,004), la regurgitación mitral no severa (OR = 2,38; IC del 95%,1,40-80; p = 0,020) y las lesiones coronarias (OR = 2,09;IC del 95%, 1,26-51; p = 0,027).Resultados. Tras seguimiento medio de 42,59 ± 40,83meses, la mortalidad global fue del 18,8% y la cardiovascular, del 11,3%. Sólo el bajo gasto cardiaco postoperatorio(OR = 4,40; IC del 95%, 1,20-15,50; p = 0,02)se relacionó con mayor mortalidad en el seguimiento. El70,5% presentó mejoría precoz de la función ventricular, siendo predictores de ausencia de mejoría el infarto previo(p = 0,04), las lesiones coronarias no revascularizadas (p = 0,04) y un gradiente aórtico reducido (p = 0,02). El93,4% mejoró su grado funcional significativamente durante el seguimiento. Conclusiones. Pese a la considerable mortalidad postoperatoria precoz de los pacientes con estenosis aórtica y disfunción ventricular izquierda, a largo plazo se observa una supervivencia elevada junto a mejora de la función ventricular y del grado funcional (AU)

Introduction and objectives. At present, surgery is the only recommended effective treatment for severe aortic stenosis. However, the surgical risk is increased when left ventricular dysfunction is present. The aim of this study was to identify predictors of postoperative and long-term mortality and functional improvement after valve replacement in patients with severe aortic stenosis and left ventricular dysfunction. Methods. Between 1996 and 2008, 635 consecutive patients with severe aortic stenosis underwent surgery. Early postoperative mortality in the 82 with an ejection fraction <40% was 19.5%. The following independent predictors of early postoperative mortality were identified: female sex (odds ratio [OR]=2.60; 95% confidence interval[CI], 2.20-89.0; P=.004), mild mitral regurgitation (OR=2.38;95% CI, 1.40-80.0; P=.020) and coronary artery disease(OR=2.09; 95% CI, 1.26-51.0; P=.027).Results. During the mean follow-up period of42.59±40.83 months, overall mortality was 18.8% and cardiovascular mortality was 11.3%. The only factor associated with increased mortality during follow-up was allow postoperative cardiac output (OR=4.40; 95% CI, 1.20-15.5; P=.02). In total, 70.5% showed early improvement in ventricular function, the predictors of which were: no improvement following a previous myocardial infarction(P=.04), no revascularized coronary lesions (P=.04), and a low aortic valve pressure gradient (P=.02). Functional class improved significantly during follow-up in 93.4% of patients. Conclusions. Despite considerable early postoperative mortality in patients with aortic stenosis and left ventricular dysfunction, over the long term there was evidence of better survival coupled to improved ventricular function and functional class (AU)