Clinical Outcome of High-Risk Patients with Severe Aortic Stenosis and Reduced Left Ventricular Ejection Fraction Undergoing Medical Treatment or TAVI

Introduction: Reduced left ventricular function in patients with severe symptomatic valvular aortic stenosis is associated with impaired clinical outcome in patients undergoing surgical aortic valve replacement (SAVR). Transcatheter Aortic Valve Implantation (TAVI) has been shown non-inferior to SAVR in high-risk patients with respect to mortality and may result in faster left ventricular recovery. Methods: We investigated clinical outcomes of high-risk patients with severe aortic stenosis undergoing medical treatment (n = 71) or TAVI (n = 256) stratified by left ventricular ejection fraction (LVEF) in a prospective single center registry. Results: Twenty-five patients (35%) among the medical cohort were found to have an LVEF <= 30% (mean 26.7 +/- 4.1%) and 37 patients (14%) among the TAVI patients (mean 25.2 +/- 4.4%). Estimated peri-interventional risk as assessed by logistic EuroSCORE was significantly higher in patients with severely impaired LVEF as compared to patients with LVEF>30% (medical/TAVI 38.5 +/- 13.8%/40.6 +/- 16.4% versus medical/TAVI 22.5 +/- 10.8%/22.1 +/- 12.8%, p <0.001). In patients undergoing TAVI, there was no significant difference in the combined endpoint of death, myocardial infarction, major stroke, life-threatening bleeding, major access-site complications, valvular re-intervention, or renal failure at 30 days between the two groups (21.0% versus 27.0%, p = 0.40). After TAVI, patients with LVEF <= 30% experienced a rapid improvement in LVEF (from 25 +/- 4% to 34 +/- 10% at discharge, p = 0.002) associated with improved NYHA functional class at 30 days (decrease >= 1 NYHA class in 95%). During long-term follow-up no difference in survival was observed in patients undergoing TAVI irrespective of baseline LVEF (p = 0.29), whereas there was a significantly higher mortality in medically treated patients with severely reduced LVEF (log rank p = 0.001). Conclusion: TAVI in patients with severely reduced left ventricular function may be performed safely and is associated with rapid recovery of systolic left ventricular function and heart failure symptoms.