Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients - Risk stratification by low-dose dobutamine echocardiography

OBJECTIVES We sought to assess risk stratification by using dobutamine stre ss echocardiography (DSE) in patients with aortic stenosis (AS) and severe left ventricular (LV) dysfunction. BACKGROUND Few data are available on risk stratification for valve replacem ent in patients with AS, LV dysfunction and low transvalvular gradients. METHODS Low-dose DSE was performed in 45 patients (16 women and 29 men; med ian [quartile range] age in years: 75 [69 to 79]; left ventricular ejection fraction: 0.29 [0.23 to 0.32]; aortic valve area [cm(2)]: 0.7 [0.5 to 0.8] ; mean transaortic gradient [mm Hg]: 26 [21 to 33]). Patients were classifi ed into two groups: group I (n = 32, LV contractile reserve on DSE) and gro up II (n = 13, no contractile reserve). Valve replacement was performed in 24 and 6 patients in groups I and II, respectively. RESULTS Perioperative mortality was 8% in group I and 50% in group II (p = 0.014). Survival at five years after the operation was 88% in group I. Comp ared with medical therapy, valve surgery was associated with better long te rm survival in group I (hazard ratio for death [HR-D] 0.13, 95% confidence interval [CI] 0.002 to 0.49) and reduced survival in group II (HR-D 19.6, 9 5% CI 2.7 to 142). The effect of valve surgery on survival remained signifi cant in both groups after adjustment for age, diabetes, respiratory disease and hypertension. Medical therapy had the same effect in both groups. CONCLUSIONS In patients with AS, LV dysfunction and low transvalvular gradi ents, contractile reserve on DSE is associated with a low operative risk an d good long-term prognosis after valve surgery. In contrast, operative mort ality remains high in the absence of contractile reserve. (J Am Coll Cardio l 2001;37:2101-7) (C) 2001 by the American College of Cardiology.