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Perioperative outcome of low flow low gradient aortic stenosis in transcatheter aortic valve implantation. Insights from a two center study with more than 700 patients.
Markus Kofler1, Nikolaos Bonaros1, Sebastian Reinstadler2, Samir Ahad3, Tim Schäufele4, Lukas Stastny1, Gudrun Feuchtnerr5, Silvana Müller2, Ludwig Müller1, Guy Friedrich2, Michael Franz2, Michael Grimm1, Ulrich Franke3, Hardy Baumbach3.
1Medical University of Innsbruck, Cardiac Surgery, Austria, 2Medical University of Innsbruck, Cardiology, Austria, 3Robert Bosch Klinikum Stuttgart, Cardiac Surgery, Germany, 4Robert Bosch Klinikum Stuttgart, Cardiology, Germany, 5Medical University of Innsbruck, Radiology, Austria.

OBJECTIVE: Our aim was to investigate the outcome of low flow low gradient aortic stenosis (LFLG-AS) after transcatheter aortic valve implantation (TAVI). Further, we analyzed the impact of the ejection fraction (EF) on the outcome of patients with LFLG-AS after TAVI.
METHODS: From 2008 to 2015, a total of 747 consecutive patients underwent TAVI for severe AS in this two center study.
We compared patients with LFLG-AS (stroke volume index >35ml/m2 and mean gradient <40mmHG, n=113) with patients showing typical characteristics of severe aortic stenosis (n=514).
To further elucidate the impact of left ventricular ejection fraction on the perioperative outcome of patients with LFLG-AS, we divided LFLG patients into two subgroups according to the LVEF, with a cut off of 50% to distinguish between reduced and preserved LVEF. Overall mean age 81.7 (± 5.7) years, overall mean STS-score 7.0 (± 5.5) %.
VARC II- Criteria were used do define clinical endpoints.
RESULTS: Device success, early safety and clinical efficacy were not significantly different in patients with LFLG-AS (all p>0.05). The stroke rate (LFLG-AS 0.9% vs. HG-AS 3.7% p=0.148) was similar between the groups. Incidence of acute kidney injury ≥ stage 2 (LFLG-AS 20.4% vs. HG-AS 11.5% p=0.012) and renal replacement therapy (LFLG-AS 15.9% vs. HG-AS 9.3% p=0.039) were significantly higher in the LFLG- group. Perioperative mortality was significantly higher in LFLG-AS (LFLG-AS 13.3% vs. HG-AS 7.4% p=0.042).
The EF had no impact on perioperative mortality of patients with LFLG-AS (LFLG-reduced EF 10.9% vs. LFLG-preserved EF 14.0%, p=0.765).
CONCLUSIONS: Patients with LFLG-AS showed a worse outcome regarding VARC II endpoints. In our cohort, reduced ejection fraction did not impact the outcome of LFLG-AS patients undergoing transcatheter aortic valve implantation.


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