910-18-Aortic Valve Replacement in Patients with Aortic Stenosis and Low Transvalvular Gradient

It has been suggested that patients (pts) with aortic stenosis (AS), LV dysfunction, and mean gradient (MG) <30mmHg, do not benefit from aortic valve replacement (AVR) and hence should not be offered surgery. Since prognosis without operation is dismal, we reviewed our experience and describe the outcome of 29 consecutive pts with MG <30mmHg and EF ≤35% who underwent AVR between 1985 and 1992; (20 M:9 F, mean age 70±12 yrs). Ninety percent (26/29) of pts were severely symptomatic (NYHA Class III or IV).Preoperative hemodynamics demonstrated the following mean values: EF 24±7%, MG 23±4mmHg, aortic valve area 0.7±0.2cm2, cardiac output 3.4±1.1L/min, and peak Doppler aortic velocity 3.3±0.4m/sec. Coronary artery disease (CAD) (≥2 vessel CAD or left main) was present in 16 pts (55%), 13/29 (45%) had prior MI (2 prior CABG). Coronary bypass at the time of AVR was performed in 17 pts.The in-hospital mortality was 24% (7/29). One and 5-year survival was 63% and 40% respectively, at a median follow-up of 1 yr, (up to 7 yrs). The presence of substantial CAD was similar among pts who survived or died perioperatively. Mean age of surgical survivors was 68±13 yrs vs 78±5 yrs for pts who died in the perioperative period (p=0.059). Clinical follow-up was available in 19/22 survivors, 15 of whom improved ≥1 NYHA Class. Eleven pts were asymptomatic (NYHA Class I) and 5 were Class II at follow-up. Postop EF in 19 survivors had improved, mean postop EF 35±14%.Conclusion(1) Pts with AS, LV systolic dysfunction and MG <30mmHg represent a high risk subset; (2) these pts have an increased operative mortality (24%); (3) however, EF and symptomatic improvement occurs in the majority of survivors. Based on this experience we conclude that pts with AS, reduced LVEF and low MG should not be denied AVR