Is it ever worth contemplating an aortic valve replacement on patients with low gradient severe aortic stenosis but poor left ventricular function with no contractile reserve?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is worth performing aortic valve replacement in patients with severe aortic stenosis and poor left ventricular function but no contractile reserve on dobutamine stress testing. Altogether 251 papers were identified using the below mentioned search and all major international guidelines were included. Fourteen presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that patients with severe aortic stenosis and a contractile reserve of <20% improvement in stroke volume on dobutamine stress testing have a very poor prognosis of only 10-20% at two years. Heart transplant would offer the best chance of survival to those eligible but for those not eligible, a surgical option should not be discounted for selected patients. The American Heart Association guidelines state that prognosis is very poor for either medical or surgical treatment, but the European Society of Cardiology guidelines state that surgery can be performed in these patients but should take into account the clinical condition of the patient. The operative mortality is around 30% and the French Multicentre study on low gradient aortic stenosis has shown that if the patient survives there is likely to be an improvement in symptoms and ejection fraction. Thus, absence of contractile reserve on stress testing does not exclude myocardial recovery after surgery, although it is a strong predictor for operative mortality. It should be noted that surgery has only been reported in very few of these patients to date. B-natriuretic peptide has also been suggested as a further marker of better prognosis in these high-risk patients in one small study.