Outcomes and Survival with Aortic Valve Replacement Compared with Medical Therapy in Patients with Low-, Moderate-, and Severe-Gradient Severe Aortic Stenosis and Normal Left Ventricular Ejection Fraction

Background: This study determined outcomes and survival with aortic valve replacement (AVR) versus medical therapy in patients with normal left ventricular ejection fraction (LVEF) with severely reduced aortic valve areas (AVA) but nonsevere mean gradients. Methods: We identified 248 aortic stenosis (AS) patients with LVEF >= 50% and echocardiographic AVA < 1.0 cm2. Group 1 had low-gradient: < 30 mmHg mean gradient; group 2 (moderate: 30 to 40 mm Hg); and group 3 (severe: > 40 mm). Results: There were 94, 87, and 67 patients in groups 1, 2, and 3. Incidence of death in groups 1, 2, and 3 were 55%, 39%, and 39% (P not significant). Incidence of AVR in groups 1, 2, and 3 were 23%, 53%, and 49% (P < 0.0001 for group 1 vs. 2; P = 0.0003 for group 1 vs. group 3). Incidence of AVR or death was 71%, 77%, and 76% (P not significant). AVR (hazard ratio = 0.30; 95% CI, 0.18, 0.51; P < 0.0001) and mitral annular calcification (hazard ratio = 2.33; 95% CI, 1.40, 3.88; P = 0.001) were independently associated with time to mortality. Kaplan-Meier curves for time to death did not differ significantly among the three groups. Kaplan-Meier survival curves for patients with and without AVR showed patients in all three groups who underwent AVR had significantly greater survival. Conclusion: Among patients with normal LVEF and AVA < 1.0 cm2, overall survival does not differ among those with low-, moderate-, or severe-aortic valve gradients. Survival is significantly improved with AVR, regardless of gradient. (Echocardiography 2011;28:378-387).