Aortic valve replacement in patients with aortic stenosis and severe left ventricular dysfunction

Background: The outcome of aortic valve replacement for severe aortic steno sis is worse in patients with impaired left ventricular function. Such dysf unction in aortic stenosis may be reversible if caused by afterload mismatc h, but not if it is caused by superimposed myocardial infarction. Methods: From our echocardiography database, 55 patients with severe aortic stenosis (valve area less than or equal to 0.75 cm(2)) and ejection fracti ons of 30% or lower who subsequently underwent aortic valve replacement wer e included. The operative mortality and clinical follow-up were detailed. Results: There were 10 perioperative deaths (operative mortality, 18%). Twe nty (36%) of the 55 patients had a prior myocardial infarction. In the 35 p atients without prior myocardial infarction, there was only 1 death (3%). I n contrast, 9 of 20 patients with prior myocardial infarction died (mortali ty rate, 45%; P less than or equal to.001). The factors significantly assoc iated with perioperative death on univariate analysis (functional class, me an aortic gradient, and prior myocardial infarction) were entered into a mo del for stepwise logistic regression. This multivariate analysis showed tha t only prior myocardial infarction was independently associated with periop erative death (odds ratio, 14.9; 95% confidence interval, 2.4-92.1; P = .00 4). Conclusions: The risk of aortic valve replacement in patients with severe a ortic stenosis and severely reduced left ventricular systolic function is e xtremely high if the patients have had a prior myocardial infarction. This information should be factored into the risk-benefit analysis that is done preoperatively for these patients, and it may preclude operation for some.