Pre-operative heart failure worsens outcome after aortic valve replacement irrespective of left ventricular ejection fraction

Abstract

Abstract Aims Left ventricular ejection fraction (LVEF) affects the outcome of aortic valve replacement (AVR) in aortic stenosis (AS). The study aim was to investigate the prognostic importance of concomitant cardiovascular disease in relation to pre-operative LVEF. Methods and results All adult patients undergoing AVR due to AS 2008–14 in a national register for heart diseases were included. All-cause mortality and hospitalization for heart failure during follow-up after AVR, stratified by preserved or reduced LVEF (≤50%), were derived from national patient registers and analysed by Cox regression. During the study period, 10 406 patients, median age 73 years, a median follow-up of 35 months were identified. Preserved LVEF was present in 7512 (72.2%). Among them, 647 (8.6%) had a history of heart failure (HF) and 1099 (14.6%) atrial fibrillation (AF) before the intervention. Pre-operative HF was associated with higher mortality irrespective of preserved or reduced LVEF: hazard ratio (HR) 1.64 [95% confidence interval (CI) 1.35–1.99] and 1.58 (95% CI 1.30–1.92). Prior AF was associated with a higher risk of mortality in patients with preserved but not in those with reduced LVEF: HR 1.62 (95% CI 1.36–1.92) and 1.05 (95% CI 0.86–1.28). Irrespective of LVEF, pre-operative HF and AF were associated with an increased risk of post-operative heart failure hospitalization. Conclusion In patients planned for AVR, a history of HF or AF, irrespective of LVEF, worsens the post-operative prognosis. Heart failure and AF can be seen as markers of myocardial fibrosis not necessarily discovered by LVEF and the merely use of it, besides symptoms, for the timing of AVR seems suboptimal.