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(Circulation. 2006;114:I-553 – I-558.)
© 2006 American Heart Association, Inc.

Surgery for Valvular Heart Disease

Long-Term Outcomes After Valve Replacement for Low-Gradient Aortic Stenosis

Impact of Prosthesis-Patient Mismatch

Alexander Kulik, MD; Ian G. Burwash, MD; Varun Kapila, BSc; Thierry G. Mesana, MD, PhD; Marc Ruel, MD, MPH

From the Division of Cardiac Surgery (A.K., V.K., T.G.M., M.R.), the Division of Cardiology (I.G.B.), and the Department of Epidemiology (M.R.), University of Ottawa, Ottawa, Ontario, Canada.

Correspondence to Marc Ruel, University of Ottawa Heart Institute, 40 Ruskin St, Suite 3403, Ottawa, Ontario, Canada K1Y 4W7. E-mail mruel{at}ottawaheart.ca

Background— The long-term outcomes of patients with low-gradient aortic stenosis (LGAS) after aortic valve replacement (AVR) are poorly defined. The purpose of this study was to define the long-term outcomes of LGAS patients after AVR and to evaluate the potential impact of prosthesis–patient mismatch (PPM) in these patients.

Methods and Results— A cohort of 664 patients undergoing AVR for aortic stenosis after 1990 were followed-up prospectively with annual clinical assessment and echocardiography (total follow-up 3447 patient-years; mean follow-up 5.2±3.3 years). LGAS was defined as an aortic valve area <1.2 cm², a mean transvalvular pressure gradient <40 mm Hg, and a left ventricular (LV) ejection fraction <50%, and was present in 79 patients. Rates and correlates of survival, freedom from congestive heart failure (CHF), and LV mass regression after AVR were determined using multivariate regression methods. Ten-year survival and freedom from CHF after AVR were 72.7±7.5% and 68.2±9.5%, respectively, for patients with LGAS, compared with 89.6±1.8% and 84.1±4.2% for patients without LGAS (hazard ratio [HR] for death and postoperative CHF, 3.1±1.1 and 2.7±0.9, respectively; P<0.01). In LGAS patients, PPM, defined as an indexed effective orifice area 0.85 cm²/m², was independently associated with increased rates of CHF (HR, 3.6±2.2; P=0.039), impaired LV mass regression (P=0.037), and a trend toward increased late mortality (HR, 3.0±1.9; P=0.084).

Conclusions— Patients with LGAS have worse long-term outcomes after AVR compared with patients without LGAS. PPM adversely affects the long-term outcomes of LGAS patients and should be avoided in this population.

Key Words: aortic stenosis • aortic valve replacement • prosthesis–patient mismatch