Aortic Valve Replacement or Heart Transplantation in Patients With Aortic Stenosis and Severe Left Ventricular Dysfunction

Aortic Valve Disease, Transcatheter Aortic Valve Replacement, and the Heart Failure Patient: A State-of-the-Art Review

Concomitant aortic stenosis (AS) in heart failure (HF) is associated with high rates of mortality and morbidity. Current guidelines recommend aortic valve replacement in patients with severe symptomatic AS and asymptomatic AS with left ventricular ejection fraction <50% and during other cardiac surgeries. Transcatheter aortic valve replacement (TAVR) has now allowed for the treatment of severe AS in previously inoperable or high-surgical-risk patients. Leveraging multimodality imaging techniques is increasingly recognized for reinforcing the rationale for intervening early, thus mitigating the risk of ongoing progression to advanced HF. There are increasing data in favor of TAVR in diverse clinical scenarios, particularly asymptomatic AS and moderate AS. Limited information is, however, available regarding the advantages of HF medical therapy before and after intervention. This review aims to comprehensively examine the phenotypes of AS in the context of HF progression, while exploring the evolving role of TAVR in specific populations.

High-risk cardiac surgery as an alternative to transplant or mechanical support in patients with end-stage heart failure

OBJECTIVE

Although the results of cardiac surgery in patients with poor left ventricular function have been widely published, the outcomes in patients with end-stage heart failure who meet criteria for advanced therapies are not well investigated. As access to transplantation and ventricular assist device therapy remains limited, we explored the possibility of conventional surgery as an alternative option for highly selected patients with end-stage heart failure.

METHODS

We identified patients with left ventricular ejection fraction <20% and VO₂ max <14 mL/min/m², who were initially referred for advanced therapies but were instead offered a conventional procedure from 2002 to 2012. We examined the short- and midterm outcomes and compared survival with that after our advanced therapies in the same era.

RESULTS

A total of 133 patients were identified; 68 were deemed to be transplant-eligible, whereas 65 were transplant-ineligible. Seventy-nine percent were in New York Heart Association class III/IV. In-hospital mortality was 12%. Actuarial survival at 5 and 10 years was 72% ± 4% and 39% ± 8%, respectively. Nonischemic etiology was identified as a predictor of late mortality. In the propensity-adjusted model, our transplant-eligible patients had comparable long-term survival to our transplantation patients (HR 1.48 [95% confidence interval, 0.66-3.2], P = .34), whereas the survival in our transplant-ineligible subset was comparable to the survival after our left ventricular assist device therapy (HR 0.49 [95% confidence interval, 0.16-1.50], P = .21).

CONCLUSIONS

Despite high perioperative risk, the midterm survival after conventional surgery in patients eligible for advanced therapies seems to be acceptable and may be an alternative option for highly selected patients with end-stage heart failure.