Survival with aortic valve replacement in asymptomatic individuals with severe aortic stenosis and a left ventricular ejection fraction of 50% to 54%

OBJECTIVES: Severe aortic stenosis (AS) with a left ventricular ejection fraction (LVEF) of 50% to 54% is associated with worse outcomes than an LVEF greater than or equal to 55%. European guidelines consider aortic valve replacement (AVR) a Class IIa indication for asymptomatic patients with an LVEF of less than 55%, whereas American guidelines recommend AVR when the LVEF is less than 50%. The authors assessed outcomes of AVR vs conservative management in this range where guidelines differ. METHODS: A registry was created for individuals with severe high-gradient AS (AVA ≤ 1 cm²), an LVEF of 50% to 54%, and a mean gradient greater than or equal to 40 mm Hg from 2000 to 2022 using queries of transthoracic echocardiogram (TTE) reports. Only asymptomatic cases were included; time-zero was defined as the time of the index TTE, and both AVR (considered as a time-dependent covariate) and mortality could occur at any point after. Proportional hazard modeling assessed the AVR-mortality association, with subset analyses for individuals with AVAs of less than 0.9 cm² and less than or equal to 0.75 cm². RESULTS: Among 693 included individuals, 83 were asymptomatic at their index TTE. Of these, 38 (45.8%) underwent AVR within 2 years. After adjusting for immortal time, individuals with AVR had a trend toward decreased mortality (HR, 0.56; 95% CI, 0.31-1.01; P = .054). Among individuals with AVAs of less than 0.9 cm² and less than or equal to 0.75 cm², AVR was associated with improved survival (HR, 0.42; 95% CI, 0.21-0.84; P less tan .01 and HR, 0.33; 95% CI, 0.15-0.75; P less than .008, respectively). CONCLUSIONS: AVR within 2 years was associated with improved survival among asymptomatic individuals with high-grade severe AS and an LVEF of 50% to 54%.