Impact of Right Ventricular Systolic Dysfunction on Outcome in Aortic Stenosis
Résumé
BACKGROUND: Pulmonary hypertension is an established outcome predictor in patients with aortic stenosis (AS), but the prognostic impact of right ventricular dysfunction has not been well studied. METHODS: We included 2181 patients (50.4% men; mean age, 77 years) with aortic valve area <1.3 cm(2) and analyzed the occurrence of all-cause death during follow-up according to tricuspid annular plane systolic excursion (TAPSE) quartiles. RESULTS: Patients in the lowest quartile (TAPSE <17 mm) were at a high risk of death, whereas survival was comparable for the 3 other quartiles. Five-year survival was 55 +/- 2% for TAPSE <17 mm, 72 +/- 2% for TAPSE of 17 to 20 mm, 71 +/- 2% for TAPSE of 20 to 24 mm, and 73 +/- 2% for TAPSE >24 mm (overall P<0.001). TAPSE <17 mm was associated with increased mortality after adjustment for established prognostic factors (adjusted hazard ratio [HR], 1.55 [95% CI, 1.21-1.97]) and after further adjustment for aortic valve replacement (AVR; adjusted HR, 1.47 [95% CI, 1.15-1.87]). The excess mortality risk associated with TAPSE <17 mm was noticed in both patients managed initially conservatively (adjusted HR, 1.46 [95% CI, 1.20-1.76]) and patients who underwent early (within 3 months after diagnosis) AVR (adjusted HR, 1.61 [95% CI, 1.03-2.52]). In asymptomatic patients with severe AS and preserved ejection fraction, TAPSE <17 mm was independently predictive of mortality (adjusted HR, 2.14 [95% CI, 1.31-3.51]). Early AVR was associated with similar survival benefit in TAPSE <17 and >= 17 mm (adjusted HR, 0.23 [95% CI, 0.16-0.34] for TAPSE <17 mm, adjusted HR, 0.26 [95% CI, 0.19-0.35] for TAPSE >= 17 mm; P for interaction, 0.97). CONCLUSIONS: Right ventricular dysfunction is an important and independent predictor of mortality in AS. TAPSE <17 mm at the time of AS diagnosis is a marker of poor survival under conservative management and after AVR even in asymptomatic patients with severe AS. AVR was associated with a pronounced reduction in mortality independent of TAPSE suggesting that AVR should be discussed before right ventricular dysfunction occurs in severe AS.