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Comparison of the Results of Aortic Valve Replacement With or Without Concomitant Coronary Artery Bypass Grafting in Patients With Left Ventricular Ejection Fraction ≤30% Versus Patients With Ejection Fraction >30%

      The present study was designed to test the hypothesis that low-ejection fraction (EF), low-gradient aortic stenosis (AS) is a predictor of major morbidity after aortic valve replacement (AVR). We retrospectively analyzed prospectively collected data from 597 consecutive patients with AS (mean age 72 ± 11 years) who had undergone AVR or combined AVR and coronary artery bypass grafting (CABG) from 1998 to 2006 (EF ≤30% in 73 [12%]). The outcome measures included hospital mortality, major complications, and long-term survival. The overall hospital mortality rate was 4% (low-EF AS 5%; low-EF AS plus CABG 8%; AS controls 4%; AS plus CABG controls 3%; p = 0.42). Low-EF, low-gradient AS was not an independent risk factor for hospital mortality but predicted stroke (odds ratio [OR] 4.3), deep sternal wound infection (OR 10.0), sepsis (OR 6.8), gastrointestinal complications (OR 4.2), and respiratory failure (OR 4.4). The survival rate at 1, 3, and 5 years was 69 ± 8%, 69 ± 8%, and 65 ± 8% in the low-EF, low-gradient, AVR plus CABG group and 95 ± 4%, 92 ± 5%, and 82 ± 7% in the low-EF, low-gradient AVR group compared to 93 ± 2%, 88 ± 2%, and 78 ± 3% in the AVR plus CABG control group and 93 ± 2%, 89 ± 2%, and 85 ± 3% in the AVR control group (p = 0.001), respectively. In the patients with low-EF AS who experienced major postoperative morbidity, the 1-year survival rate was significantly reduced (54 ± 14%) compared to those who did not (95 ± 3%, p <0.001). In conclusion, low-EF, low-gradient AS is a predictor of increased major morbidity after AVR, which nonetheless remains the treatment of choice for most patients because of the excellent early and late survival. However, patients with strong risk factors for postoperative renal and respiratory failure might derive less benefit from conventional surgical AVR.
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      References

        • Bonow R.O.
        • Carabello B.A.
        • Kanu C.
        • de Leon Jr, A.C.
        • Faxon D.P.
        • Freed M.D.
        • Gaasch W.H.
        • Lytle B.W.
        • Nishimura R.A.
        • O'Gara P.T.
        • O'Rourke R.A.
        • Otto C.M.
        • Shah P.M.
        • Shanewise J.S.
        • Smith Jr, S.C.
        • Jacobs A.K.
        • Adams C.D.
        • Anderson J.L.
        • Antman E.M.
        • Faxon D.P.
        • Fuster V.
        • Halperin J.L.
        • Hiratzka L.F.
        • Hunt S.A.
        • Lytle B.W.
        • Nishimura R.
        • Page R.L.
        • Riegel B.
        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. 2006; 114: e84-e231
        • Iung B.
        • Cachier A.
        • Baron G.
        • Messika-Zeitoun D.
        • Delahaye F.
        • Tornos P.
        • Gohlke-Barwolf C.
        • Boersma E.
        • Ravaud P.
        • Vahanian A.
        Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery?.
        Eur Heart J. 2005; 26: 2714-2720
        • Levy F.
        • Laurent M.
        • Monin J.L.
        • Maillet J.M.
        • Pasquet A.
        • Le Tourneau T.
        • Petit-Eisenmann H.
        • Gori M.
        • Jobic Y.
        • Bauer F.
        • Chauvel C.
        • Leguerrier A.
        • Tribouilloy C.
        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. 2008; 51: 1466-1472
        • Connolly H.M.
        • Oh J.K.
        • Orszulak T.A.
        • Osborn S.L.
        • Roger V.L.
        • Hodge D.O.
        • Bailey K.R.
        • Seward J.B.
        • Tajik A.J.
        Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction: prognostic indicators.
        Circulation. 1997; 95: 2395-2400
        • Powell D.E.
        • Tunick P.A.
        • Rosenzweig B.P.
        • Freedberg R.S.
        • Katz E.S.
        • Applebaum R.M.
        • Perez J.L.
        • Kronzon I.
        Aortic valve replacement in patients with aortic stenosis and severe left ventricular dysfunction.
        Arch Intern Med. 2000; 160: 1337-1341
        • Rothenburger M.
        • Drebber K.
        • Tjan T.D.
        • Schmidt C.
        • Schmid C.
        • Wichter T.
        • Scheld H.H.
        • Deiwick M.
        Aortic valve replacement for aortic regurgitation and stenosis, in patients with severe left ventricular dysfunction.
        Eur J Cardio Thorac Surg. 2003; 23: 703-709
        • Monin J.L.
        • Monchi M.
        • Gest V.
        • Duval-Moulin A.M.
        • Dubois-Rande J.L.
        • Gueret P.
        Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients: risk stratification by low-dose dobutamine echocardiography.
        J Am Coll Cardiol. 2001; 37: 2101-2107
        • Pereira J.J.
        • Lauer M.S.
        • Bashir M.
        • Afridi I.
        • Blackstone E.H.
        • Stewart W.J.
        • McCarthy P.M.
        • Thomas J.D.
        • Asher C.R.
        Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction.
        J Am Coll Cardiol. 2002; 39: 1356-1363
        • Baumgartner H.
        • Hung J.
        • Bermejo J.
        • Chambers J.B.
        • Evangelista A.
        • Griffin B.P.
        • Iung B.
        • Otto C.M.
        • Pellikka P.A.
        • Quinones M.
        Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice.
        J Am Soc Echocardiogr. 2009; 22 (quiz 101–102): 1-23
      1. Adult cardiac Surgery in New York State 2001–2003.
        (Accessed April 15, 2007)
        • Nashef S.A.
        • Roques F.
        • Michel P.
        • Gauducheau E.
        • Lemeshow S.
        • Salamon R.
        European system for cardiac operative risk evaluation (EuroSCORE).
        Eur J Cardio Thorac Surg. 1999; 16: 9-13
        • Schiller N.B.
        • Shah P.M.
        • Crawford M.
        • DeMaria A.
        • Devereux R.
        • Feigenbaum H.
        • Gutgesell H.
        • Reichek N.
        • Sahn D.
        • Schnittger I.
        • et al.
        Recommendations for quantitation of the left ventricle by two-dimensional echocardiography.
        J Am Soc Echocardiogr. 1989; 2: 358-367
        • Oh J.K.
        • Taliercio C.P.
        • Holmes Jr, D.R.
        • Reeder G.S.
        • Bailey K.R.
        • Seward J.B.
        • Tajik A.J.
        Prediction of the severity of aortic stenosis by Doppler aortic valve area determination: prospective Doppler-catheterization correlation in 100 patients.
        J Am Coll Cardiol. 1988; 11: 1227-1234
        • Bergler-Klein J.
        • Mundigler G.
        • Pibarot P.
        • Burwash I.G.
        • Dumesnil J.G.
        • Blais C.
        • Fuchs C.
        • Mohty D.
        • Beanlands R.S.
        • Hachicha Z.
        • Walter-Publig N.
        • Rader F.
        • Baumgartner H.
        B-type natriuretic peptide in low-flow, low-gradient aortic stenosis: relationship to hemodynamics and clinical outcome: results from the Multicenter Truly or Pseudo-Severe Aortic Stenosis (TOPAS) study.
        Circulation. 2007; 115: 2848-2855
        • Hosmer D.W.
        • Lemeshow S.
        Applied Logistic Regression.
        Wiley, New York1989
        • Carabello B.A.
        • Green L.H.
        • Grossman W.
        • Cohn L.H.
        • Koster J.K.
        • Collins Jr, J.J.
        Hemodynamic determinants of prognosis of aortic valve replacement in critical aortic stenosis and advanced congestive heart failure.
        Circulation. 1980; 62: 42-48
        • Connolly H.M.
        • Oh J.K.
        • Schaff H.V.
        • Roger V.L.
        • Osborn S.L.
        • Hodge D.O.
        • Tajik A.J.
        Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction: result of aortic valve replacement in 52 patients.
        Circulation. 2000; 101: 1940-1946
        • Monin J.L.
        • Quere J.P.
        • Monchi M.
        • Petit H.
        • Baleynaud S.
        • Chauvel C.
        • Pop C.
        • Ohlmann P.
        • Lelguen C.
        • Dehant P.
        • Tribouilloy C.
        • Gueret P.
        Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics.
        Circulation. 2003; 108: 319-324
        • Birkmeyer J.D.
        • Siewers A.E.
        • Finlayson E.V.
        • Stukel T.A.
        • Lucas F.L.
        • Batista I.
        • Welch H.G.
        • Wennberg D.E.
        Hospital volume and surgical mortality in the United States.
        N Engl J Med. 2002; 346: 1128-1137
        • Gammie J.S.
        • O'Brien S.M.
        • Griffith B.P.
        • Ferguson T.B.
        • Peterson E.D.
        Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation.
        Circulation. 2007; 115: 881-887
        • Rankin J.S.
        • Hammill B.G.
        • Ferguson Jr, T.B.
        • Glower D.D.
        • O'Brien S.M.
        • DeLong E.R.
        • Peterson E.D.
        • Edwards F.H.
        Determinants of operative mortality in valvular heart surgery.
        J Thorac Cardiovasc Surg. 2006; 131: 547-557
        • Cribier A.
        • Eltchaninoff H.
        • Tron C.
        • Bauer F.
        • Agatiello C.
        • Sebagh L.
        • Bash A.
        • Nusimovici D.
        • Litzler P.Y.
        • Bessou J.P.
        • Leon M.B.
        Early experience with percutaneous transcatheter implantation of heart valve prosthesis for the treatment of end-stage inoperable patients with calcific aortic stenosis.
        J Am Coll Cardiol. 2004; 43: 698-703