Is there an outcome penalty linked to guideline-based class-I indications for valvular surgery? long-term analysis of patients with high gradient severe aortic stenosis

Background: Current ACC/AHA guidelines recommend aortic valve replacement (AVR) as class-I triggers in patients with high-gradient severe aortic stenosis (HGSAS) in presence of symptoms and/or left ventricular dysfunction (LVEF<50%). Whether waiting for these triggers could be associated with long-term outcome penalty after AVR remains poorly studied. Objective: To examine the impact of guideline-based class-I triggers on long-term post-operative survival in patients with HGSAS. Methods: We used an international registry including consecutive patients operated on for HGSAS between 2000 and 2017. 2030 Patients were included in the analysis and retrospectively classified according to the guideline-based indication: no Class-I trigger (no symptoms and LVEF>50%, n=853), Symptoms with LVEF>50% (n=965), or LVEF<50% (regardless of symptoms, n=212). Survival was compared in a multivariate Cox-model and after inverse probability weighting-[IPW] for relevant variables. Finally, we explored the most sensitive left ventricular ejection fraction threshold for predicting mortality risk. Results: 10-years survival was better among patients without any class-I trigger than with symptoms or LVEF<50% (67±3 vs 56±3 vs 53±7% respectively, p<0.001). After adjustment for covariates, risk of death increased significantly when patients were operated on with symptoms (HR: 1.48, [95%CI: 1.17-1.86]) or with LVEF<50% (HR: 1.47, [95%CI: 1.05-2.06]) compared to patients with no class-I trigger. Furthermore, LVEF<55% emerged as a more sensitive threshold for the prediction of post-operative mortality in comparison with LVEF<50% (see table), allowing a better separation of survival curves and indicating that patients with LVEF 50-55% are already at risk with long term consequences even after AVR. Interestingly, among asymptomatic patients with LVEF >55%, performing AVR restituted a normal life expectancy (comparable to the Belgian population of same age, see figure). Finally, the outcome penalty after AVR when waiting for symptoms or LVEF<55% was confirmed in IPW analysis (HR: 1.43, [95%CI: 1.13-1.82] and HR: 1.63, [95%CI: 1.19-2.23], respectively). Conclusions: Guideline-based Class-I triggers for AVR in patients with HGSAS is associated with profound outcome consequences on long-term postoperative mortality. Our data argue that patients with HGSAS should be operated on before the onset of these triggers. Finally, our data suggest that a threshold of LVEF<55% is a stronger predictor of outcome than LVEF<50%.

Affiliations

UCLouvainSSS/IREC/CARD - Pôle de recherche cardiovasculaire

Citations

APA
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De Azevedo Coutinho Pereira, D., Boute, M., Hanet, V., Christophe Tribouilloy, Sylvestre Marechaux, Alexandre Altes, Yohann Bohbot, Dan Rusimaru, N Tellier, Pouleur, A.-C., Pasquet, A., Gerber, B., Vanoverschelde, J.-L., & Vancraeynest, D. (2023). Is there an outcome penalty linked to guideline-based class-I indications for valvular surgery? long-term analysis of patients with high gradient severe aortic stenosis. European Heart Journal, 44(Suppl 2), ehad655. 1694. https://doi.org/10.1093/eurheartj/ehad655.1694 (Original work published 2023)