Author + information
- Tobias Schmidt1,
- Jury Schewel1,
- Michael Schlüter2,
- Hannes Alessandrini3,
- Michael Schmoeckel1,
- Karl-Heinz Kuck1 and
- Christian Frerker1
Only limited data exists for transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis (AS) and severely reduced left ventricular ejection fraction (LVEF). We report on TAVR procedures in patients with severe AS and LVEF ≤ 20%.
1505 TAVR procedures were performed between 07/2008 and 07/2016 at our center. 33 patients (mean age 79±7 years; 24 men; median logisticEuroSCORE (log.ES) 38% (interquantil range 24;63); NYHA II, III and IV in 4, 15 and 14 pts, respectively) had a LVEF ≤20%. Access way was mainly transfemoral with 91% (30/33).
Echocardiographic mean LVEF increased from 19±2% before the procedure to 27±11% (p=0.0001) at discharge. Right heart catheterization showed an increase in cardiac output (CO) from 3.9±1.0 to 4.3±1.2l/min (p=0.0048) and stroke volume (SV) from 56±20 to 62±18ml (p=0.028). Transvalvular aortic gradient decreased from 29±12mmHg to 6±3mmHg (mean gradient) and 31±18mmHg to 1±2mmHg (peak-to-peak gradient; both p=0.0001). Device success was achieved in 94% (31/33). Two patients died during or <72h after the procedure. Overall 8 patients (24%) were in cardiogenic shock before the procedure. Patients were followed for a median of 4.8 (IQR, 1.2-16.3) months. 30-day mortality was 18% (6/33), while 4 of these patients were in cardiogenic shock prior to the procedure. Separating patients to higher and lower than the median log.ES of 38%, 30-day mortality is 0% (0/16) for patients with log.ES <38 compared to 37.5% (6/16) with log.ES ≥38 (one patient missing for 30-day follow up).
TAVR in patients with severe AS and severe reduced LVEF show high 30-day mortality. 30-day mortality was driven by cardiogenic shock and high log.ES. Indication for TAVR in these patients (high log.ES and cardiogenic shock) needs to be intensively discussed before the procedure specifically for each patient. Patients with lower log.ES seem to have a low 30-day mortality. High device success shows that the procedure in this very sick patient population is feasible and safe. Overall, echocardiographic LVEF and hemodynamic CO and SV improved directly after TAVR despite very sick patients with severe reduced LV function.
STRUCTURAL: Valvular Disease: Aortic