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Clinical Research in Cardiology

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01-01-2016 | Original Paper

Invasive hemodynamic assessments during transcatheter aortic valve implantation: comparison of patient outcomes in higher vs. lower transvalvular gradients with respect to left ventricular ejection fraction

Authors: Jury Schewel, Dimitry Schewel, Christian Frerker, Peter Wohlmuth, Karl-Heinz Kuck, Ulrich Schäfer

Published in: Clinical Research in Cardiology | Issue 1/2016

Abstract

Background

Low-flow and low-gradient (LFLG) aortic stenosis (AS), which can occur with reduced or preserved left ventricular ejection fraction (LVEF), represents a challenging patient subset. Since outcomes in patients with LFLG AS are worse following surgical aortic valve replacement, we analyzed outcomes in patients after transcatheter aortic valve implantation (TAVI) in our large database.

Methods and results

Among 841 treated patients, a total of 676 patients with complete dataset of invasive right- and left-sided hemodynamics were analyzed. Patients were subdivided into normal flow, high-gradient AS (NFHG: dPmean >40 mmHg, LVEF > 50 %), paradoxical LFLG AS (PLFLG: dPmean ≤40 mmHg, LVEF > 50 %, stroke volume index ≤35 ml/m²), and classical LFLG AS (CLFLG: dPmean ≤40 mmHg, LVEF ≤ 30 %). Finally, global hemodynamics and patient outcomes and were compared. Patients with CLFLG AS had a higher prevalence of comorbidities and much higher logistic euro SCORE (35.8 ± 21.7) compared to PLFLG AS (20.0 ± 13.1) and NFHG AS (17.0 ± 11.9). Despite high procedural success rates in all groups, patients with CLFLG AS demonstrated a much higher 30-day and 1-year mortality (NFHG/PLFLG/CLFLG 30-day: 5.9/9.6/18.3 %; 1-year: 11.4/22.4/38.2 %). Nevertheless, nearly all survivors demonstrated an improvement of functional capacity (NYHA class) and a decrease of NTproBNP levels during the follow-up.

Conclusion

The higher mortality in patients with CLFLG AS reflects an advanced disease state, possibly indicating a futile condition before TAVI. Nevertheless, high procedural success rates and a functional improvement in nearly all survivors support the concept of TAVI.

Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P (2007) Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 115:2856–2864PubMedCrossRef

Dumesnil JG, Pibarot P, Carabello B (2010) Paradoxical low flow and/or low gradient severe aortic stenosis despite preserved left ventricular ejection fraction: implications for diagnosis and treatment. Eur Heart J 31:281–289PubMedPubMedCentralCrossRef

Minners J, Allgeier M, Gohlke-Baerwolf C, Kienzle RP, Neumann FJ, Jander N (2008) Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis. Eur Heart J 29:1043–1048PubMedCrossRef

Herrmann S, Stork S, Niemann M, Lange V, Strotmann JM, Frantz S, Beer M, Gattenlohner S, Voelker W, Ertl G, Weidemann F (2011) Low-gradient aortic valve stenosis myocardial fibrosis and its influence on function and outcome. J Am Coll Cardiol 58:402–412PubMedCrossRef

Pibarot P, Dumesnil JG (2011) Paradoxical low-flow, low-gradient aortic stenosis adding new pieces to the puzzle. J Am Coll Cardiol 58:413–415PubMedCrossRef

Pai RG, Varadarajan P, Razzouk A (2008) Survival benefit of aortic valve replacement in patients with severe aortic stenosis with low ejection fraction and low gradient with normal ejection fraction. Ann Thorac Surg 86:1781–1789PubMedCrossRef

Tarantini G, Covolo E, Razzolini R, Bilato C, Frigo AC, Napodano M, Favaretto E, Fraccaro C, Isabella G, Gerosa G, Iliceto S, Cribier A (2011) Valve replacement for severe aortic stenosis with low transvalvular gradient and left ventricular ejection fraction exceeding 0.50. Ann Thorac Surg 91:1808–1815PubMedCrossRef

Christensen KL, Ivarsen HR, Thuesen L, Kristensen BO, Egeblad H (2004) Aortic valve stenosis: fatal natural history despite normal left ventricular function and low invasive peak-to-peak pressure gradients. Cardiology 102:147–151PubMedCrossRef

Fraccaro C, Al-Lamee R, Tarantini G, Maisano F, Napodano M, Montorfano M, Frigo AC, Iliceto S, Gerosa G, Isabella G, Colombo A (2012) Transcatheter aortic valve implantation in patients with severe left ventricular dysfunction: immediate and mid-term results, a multicenter study. Circ Cardiovasc Interv 5:253–260PubMedCrossRef

10.

Amabile N, Ramadan R, Ghostine S, Cheng S, Azmoun A, Raoux F, To NT, Haddouche Y, Troussier X, Nottin R, Caussin C (2013) Early and mid-term cardiovascular outcomes following TAVI: impact of pre-procedural transvalvular gradient. Int J Cardiol 167:687–692PubMedCrossRef

11.

Clavel MA, Webb JG, Rodes-Cabau J, Masson JB, Dumont E, De Larochelliere R, Doyle D, Bergeron S, Baumgartner H, Burwash IG, Dumesnil JG, Mundigler G, Moss R, Kempny A, Bagur R, Bergler-Klein J, Gurvitch R, Mathieu P, Pibarot P (2010) Comparison between transcatheter and surgical prosthetic valve implantation in patients with severe aortic stenosis and reduced left ventricular ejection fraction. Circulation 122:1928–1936PubMedCrossRef

12.

Connolly HM, Oh JK, Schaff HV, Roger VL, Osborn SL, Hodge DO, Tajik AJ (2000) Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction:result of aortic valve replacement in 52 patients. Circulation 101:1940–1946PubMedCrossRef

13.

Monin JL, Quere JP, Monchi M, Petit H, Baleynaud S, Chauvel C, Pop C, Ohlmann P, Lelguen C, Dehant P, Tribouilloy C, Gueret P (2003) Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics. Circulation 108:319–324PubMedCrossRef

14.

Tribouilloy C, Levy F, Rusinaru D, Gueret P, Petit-Eisenmann H, Baleynaud S, Jobic Y, Adams C, Lelong B, Pasquet A, Chauvel C, Metz D, Quere JP, Monin JL (2009) Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography. J Am Coll Cardiol 53:1865–1873PubMedCrossRef

15.

Quere JP, Monin JL, Levy F, Petit H, Baleynaud S, Chauvel C, Pop C, Ohlmann P, Lelguen C, Dehant P, Gueret P, Tribouilloy C (2006) Influence of preoperative left ventricular contractile reserve on postoperative ejection fraction in low-gradient aortic stenosis. Circulation 113:1738–1744PubMedCrossRef

16.

17.

Bonow RO, Carabello BA, Kanu C, de Leon ACJ, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SCJ, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B (2006) ACC/AHA 2006 guidelines 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 (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 114:e84–e231PubMedCrossRef

18.

Vaquette B, Corbineau H, Laurent M, Lelong B, Langanay T, de Place C, Froger-Bompas C, Leclercq C, Daubert C, Leguerrier A (2005) Valve replacement in patients with critical aortic stenosis and depressed left ventricular function: predictors of operative risk, left ventricular function recovery, and long term outcome. Heart 91:1324–1329PubMedPubMedCentralCrossRef

19.

Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ (2011) Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 364:2187–2198PubMedCrossRef

20.

Tamburino C, Capodanno D, Ramondo A, Petronio AS, Ettori F, Santoro G, Klugmann S, Bedogni F, Maisano F, Marzocchi A, Poli A, Antoniucci D, Napodano M, De Carlo M, Fiorina C, Ussia GP (2011) Incidence and predictors of early and late mortality after transcatheter aortic valve implantation in 663 patients with severe aortic stenosis. Circulation 123:299–308PubMedCrossRef

21.

Adams DH, Popma JJ, Reardon MJ, Yakubov SJ, Coselli JS, Deeb GM, Gleason TG, Buchbinder M, Hermiller JJ, Kleiman NS, Chetcuti S, Heiser J, Merhi W, Zorn G, Tadros P, Robinson N, Petrossian G, Hughes GC, Harrison JK, Conte J, Maini B, Mumtaz M, Chenoweth S, Oh JK (2014) Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med 370:1790–1798PubMedCrossRef

22.

Walther T, Simon P, Dewey T, Wimmer-Greinecker G, Falk V, Kasimir MT, Doss M, Borger MA, Schuler G, Glogar D, Fehske W, Wolner E, Mohr FW, Mack M (2007) Transapical minimally invasive aortic valve implantation: multicenter experience. Circulation 116:I240–I245PubMedCrossRef

23.

Tarantini G, Buja P, Scognamiglio R, Razzolini R, Gerosa G, Isabella G, Ramondo A, Iliceto S (2003) Aortic valve replacement in severe aortic stenosis with left ventricular dysfunction: determinants of cardiac mortality and ventricular function recovery. Eur J Cardiothorac Surg 24:879–885PubMedCrossRef

24.

Pereira JJ, Lauer MS, Bashir M, Afridi I, Blackstone EH, Stewart WJ, McCarthy PM, Thomas JD, Asher CR (2002) Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction. J Am Coll Cardiol 39:1356–1363PubMedCrossRef

25.

Hamm CW, Mollmann H, Holzhey D, Beckmann A, Veit C, Figulla HR, Cremer J, Kuck KH, Lange R, Zahn R, Sack S, Schuler G, Walther T, Beyersdorf F, Bohm M, Heusch G, Funkat AK, Meinertz T, Neumann T, Papoutsis K, Schneider S, Welz A, Mohr FW (2014) The German Aortic Valve Registry (GARY): in-hospital outcome. Eur Heart J 35:1588–1598PubMedPubMedCentralCrossRef

26.

Mohr FW, Holzhey D, Mollmann H, Beckmann A, Veit C, Figulla HR, Cremer J, Kuck KH, Lange R, Zahn R, Sack S, Schuler G, Walther T, Beyersdorf F, Bohm M, Heusch G, Funkat AK, Meinertz T, Neumann T, Papoutsis K, Schneider S, Welz A, Hamm CW (2014) The German Aortic Valve Registry: 1-year results from 13,680 patients with aortic valve disease. Eur J Cardiothorac Surg 46:808–816PubMedCrossRef

27.

Lauten A, Figulla HR, Mollmann H, Holzhey D, Kotting J, Beckmann A, Veit C, Cremer J, Kuck KH, Lange R, Zahn R, Sack S, Schuler G, Walther T, Beyersdorf F, Bohm M, Heusch G, Meinertz T, Neumann T, Welz A, Mohr FW, Hamm CW (2014) TAVI for low-flow, low-gradient severe aortic stenosis with preserved or reduced ejection fraction: a subgroup analysis from the German Aortic Valve Registry (GARY). EuroIntervention 10:850–859PubMedCrossRef

28.

O’Sullivan CJ, Stortecky S, Heg D, Pilgrim T, Hosek N, Buellesfeld L, Khattab AA, Nietlispach F, Moschovitis A, Zanchin T, Meier B, Windecker S, Wenaweser P (2013) Clinical outcomes of patients with low-flow, low-gradient, severe aortic stenosis and either preserved or reduced ejection fraction undergoing transcatheter aortic valve implantation. Eur Heart J 34:3437–3450PubMedCrossRef

29.

Lauten A, Zahn R, Horack M, Sievert H, Linke A, Ferrari M, Harnath A, Grube E, Gerckens U, Kuck KH, Sack S, Senges J, Figulla HR (2012) Transcatheter aortic valve implantation in patients with low-flow, low-gradient aortic stenosis. JACC Cardiovasc Interv 5:552–559PubMedCrossRef

30.

Herrmann HC, Pibarot P, Hueter I, Gertz ZM, Stewart WJ, Kapadia S, Tuzcu EM, Babaliaros V, Thourani V, Szeto WY, Bavaria JE, Kodali S, Hahn RT, Williams M, Miller DC, Douglas PS, Leon MB (2013) Predictors of mortality and outcomes of therapy in low-flow severe aortic stenosis: a Placement of Aortic Transcatheter Valves (PARTNER) trial analysis. Circulation 127:2316–2326PubMedCrossRef

31.

Le Ven F, Freeman M, Webb J, Clavel MA, Wheeler M, Dumont E, Thompson C, De Larochelliere R, Moss R, Doyle D, Ribeiro HB, Urena M, Nombela-Franco L, Rodes-Cabau J, Pibarot P (2013) Impact of low flow on the outcome of high-risk patients undergoing transcatheter aortic valve replacement. J Am Coll Cardiol 62:782–788PubMedCrossRef

32.

Levy F, Laurent M, Monin JL, Maillet JM, Pasquet A, Le Tourneau T, Petit-Eisenmann H, Gori M, Jobic Y, Bauer F, Chauvel C, Leguerrier A, Tribouilloy C (2008) Aortic valve replacement for low-flow/low-gradient aortic stenosis operative risk stratification and long-term outcome: a European multicenter study. J Am Coll Cardiol 51:1466–1472PubMedCrossRef

33.

Connolly HM, Oh JK, Orszulak TA, Osborn SL, Roger VL, Hodge DO, Bailey KR, Seward JB, Tajik AJ (1997) Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction. Prognostic indicators. Circulation 95:2395–2400PubMedCrossRef

34.

Chambers J (2006) Low “gradient”, low flow aortic stenosis. Heart 92:554–558PubMedPubMedCentralCrossRef

35.

Monin JL, Monchi M, Gest V, Duval-Moulin AM, Dubois-Rande JL, Gueret P (2001) Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients: risk stratification by low-dose dobutamine echocardiography. J Am Coll Cardiol 37:2101–2107PubMedCrossRef

36.

Nishimura RA, Grantham JA, Connolly HM, Schaff HV, Higano ST, Holmes DRJ (2002) Low-output, low-gradient aortic stenosis in patients with depressed left ventricular systolic function: the clinical utility of the dobutamine challenge in the catheterization laboratory. Circulation 106:809–813PubMedCrossRef

Title: Invasive hemodynamic assessments during transcatheter aortic valve implantation: comparison of patient outcomes in higher vs. lower transvalvular gradients with respect to left ventricular ejection fraction
Authors: Jury Schewel
Dimitry Schewel
Christian Frerker
Peter Wohlmuth
Karl-Heinz Kuck
Ulrich Schäfer
Publication date: 01-01-2016
Publisher: Springer Berlin Heidelberg
Published in: Clinical Research in Cardiology / Issue 1/2016
Print ISSN: 1861-0684
Electronic ISSN: 1861-0692
DOI: https://doi.org/10.1007/s00392-015-0889-1

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Methods and results

Conclusion

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