Transapical aortic valve implantation off-pump in patients with impaired left ventricular function

Abstract

Background: Patients with impaired left ventricular ejection fraction (LVEF) and severe aortic stenosis have a higher perioperative risk for aortic valve replacement. Transapical aortic valve implantation (TA-AVI) allows for off-pump valve implantation, which might be beneficial in the subgroup of patients with impaired LVEF.

Methods: All patients with LVEF≤40% who underwent TA-AVI for severe aortic stenosis and who fulfilled at least 1-year follow-up formed the study group. Results were compared to TA-AVI patients with preserved LVEF treated during the same time period.

Results: Thirty-nine patients with LVEF≤40% were identified, mean LVEF was 32.5±7.1%. Logistic EuroSCORE and STS-score were 43.6%±18.5% and 15.3%±9.3%, respectively. Concomitant coronary artery disease was present in 59% with 23.1% having had previous bypass surgery and 17.9% having had a history of prior myocardial infarction. Two patients required cardiopulmonary-bypass support due to intraoperative complications, and another 2 patients required cardiopulmonary-bypass for reperfusion. Median procedure time was 75 minutes (interquartile range, 65-90 minutes). LVEF at discharge increased significantly to a mean of 41.5%±10%, and at 1-year follow-up to 53.9%±13% (both p<0.0001). The proportion of patients in New York Heart Association class III-IV decreased from 92.3% to 15.0% at 1-year follow-up (p<0.001). There was neither a statistically significant difference in in-hospital mortality nor in long-term survival up to 4 years, in comparison to patients with preserved LVEF.

Conclusions: Transapical aortic valve implantation is a promising approach, allowing for off-pump treatment of elderly, high-risk patients with impaired LVEF requiring aortic valve replacement. Short-term and long-term outcomes are respectable, and an improvement in postoperative LVEF and New York Heart Association class can be anticipated.