Patient survival in severe low-flow, low-gradient aortic stenosis after aortic valve replacement or conservative management.

BACKGROUND AND AIM: Classical and paradoxical low-flow, low-gradient (LFLG) aortic stenosis (AS) are the most challenging subtypes of AS. The current therapeutic options are aortic valve replacement (AVR) and conservative management: AVR promotes long-term survival but is invasive, while conservative management yields a poor prognosis but is noninvasive since it uses no aortic valve replacement (noAVR). The present meta-analysis investigated the rate of survival of patients with LFLG AS undergoing either AVR or noAVR interventions. METHODS: The meta-analysis compared the outcomes of AVR with those of noAVR in terms of patient survival. In both groups, a meta-regression was conducted to investigate the impact on patient survival of the left ventricular ejection fraction (LVEF), either preserved (paradoxical LFLG AS) or reduced (classical LFLG AS). RESULTS: The relative risk of survival between the AVR and noAVR groups was 1.99 [1.40, 2.82] (p = .0001), suggesting that survival tends to be better in AVR patients than in noAVR patients. The meta-regression revealed that a reduced LVEF may be related to a higher survival in AVR patients when compared to a preserved LVEF (p = .04). Finally, the analysis indicated that LVEF seems not to be prognostic of survival in noAVR patients (p = .18). CONCLUSIONS: Patients with LFLG AS have better survival if they undergo AVR. In AVR patients, reduced LVEF rather than preserved LVEF is related to better survival, whereas there seems to be no difference in prognostic value between reduced and preserved LVEF in noAVR patients.

Papillary muscle intervention vs mitral ring annuloplasty in ischemic mitral regurgitation.

BACKGROUND AND AIMS: The main pathophysiological factor of chronic ischemic mitral regurgitation (MR) is the outward displacement of the papillary muscles (PMs) leading to leaflet tethering. For this reason, papillary muscle intervention (PMI) in combination with mitral ring annuloplasty (MRA) has recently been introduced into clinical practice to correct this displacement, and to reduce the recurrence of regurgitation. METHODS: A meta-analysis was conducted comparing the outcomes of PMI and MRA performed in combination vs MRA performed alone, in terms of MR recurrence and left ventricular reverse remodeling (LVRR). A meta-regression was carried out to investigate the impact of the type of PMI procedure on the outcomes. RESULTS: MR recurrence in patients undergoing both PMI and MRA was lower than in those who only had MRA (log incidence rate ratio, -0.66; lower-upper limits, -1.13 to 0.20; I2 = 0.0%; p = .44; Egger's test: intercept 0.35 [-0.78 to 1.51]; p = .42). The group with both PMI and MRA and that with only MRA showed a slightly higher reduction in left ventricular diameters (-5.94%; -8.75% to 3.13%,). However, in both groups, LVRR was <10%. No difference was detected between PM relocation/repositioning and papillary muscle approximation in terms of LVRR (p = .33). CONCLUSIONS: Using PMI and MRA together has a lower MR recurrence than using MRA alone. No significant LVRR was observed between the two groups nor between the PMI techniques employed.