TAVR in Patients with Aortic Regurgitation with Low LVEF: Clinical Outcomes and the Value of ECMO

TAVR in Patients with Aortic Regurgitation with Low LVEF: Clinical Outcomes and the Value of ECMO | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article TAVR in Patients with Aortic Regurgitation with Low LVEF: Clinical Outcomes and the Value of ECMO Yu Mao, Mengen Zhai, Ping Jin, Wenjing Li, Gejun Zhang, Haibo Zhang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8976112/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background For patients with pure aortic regurgitation (AR) with low left ventricular ejection fraction (LVEF), the net clinical benefit of current treatment options remains uncertain. Our goal was to evaluate the clinical outcomes of TAVR in such patients and the periprocedural clinical value of extracorporeal membrane oxygenation (ECMO). Methods In this multicenter study, patients who underwent TAVR between June 2017 and May 2021 were enrolled. Patients were divided into three groups based on LVEF and whether they received preventive ECMO. The primary endpoint was 2-year all-cause mortality. Results A total of 751 patients were included, including 51 patients (6.8%) in the ECMO + LVEF < 35% group, 38 patients (5.1%) in the non-ECMO + LVEF 35% group. The three groups with LVEF were 26.0 (24.0–32.0)%, 33.0 (30.0–34.0)%, and 52.0 (48.0–57.0)%. The primary endpoint of patients with LVEF 35% (Hazard ratio: 1.18; 95% CI: 0.69–2.03, P = 0.547). The 2-year LVEF of patients with LVEF < 35% was significantly increased. Notably, the ECMO + LVEF < 35% group had a lower incidence of the primary endpoint than the non-ECMO + LVEF < 35% group (hazard ratio: 0.47; 95% confidence interval: 0.17–0.82, P = 0.042). Conclusions The 2-year clinical outcomes among the three groups were similar, and LVEF was significantly improved. Timely implantation of ECMO had potential clinical value for these patients. Aortic regurgitation Transcatheter aortic valve replacement Left ventricular ejection fraction Extracorporeal membrane oxygenation Heart failure Figures Figure 1 Figure 2 Figure 3 Introduction Transcatheter aortic valve replacement (TAVR) has been recognized as an effective alternative to surgical aortic valve replacement (SAVR) in the treatment of aortic stenosis (AS). 1 , 2 Aortic regurgitant (AR) is a common aortic valve disease, and patients with symptomatic chronic severe AR have a poorer prognosis. 3 Preliminary studies have shown the safety and effectiveness of TAVR for such patients with high surgical risk. 4 Furthermore, some patients with AR also have severe left cardiac dysfunction. However, in TAVR for patients with severe AS, a left ventricular ejection fraction (LVEF) < 20% was used as the exclusion item. 5 Previous studies have shown that TAVR could significantly improve the postprocedural LVEF and the prognosis. 6 However, few studies have been reported for patients with pure AR with low LVEF. In addition, the application of an extracorporeal life support (ECLS) system in the periprocedural cardiopulmonary function protection is an effective strategy for such patients. 7 In particular, extracorporeal membrane oxygenation (ECMO), as a non-sedating, non-intubating cardiopulmonary support technique, may provide stable hemodynamic support during the periprocedural period. 8 , 9 Therefore, the goal of this study was to evaluate the clinical outcomes of TAVR in patients with pure AR with an LVEF < 35% as well as the clinical value of ECMO. Methods Study population and design This study prospectively collected 751 patients with pure AR combined with severe heart failure (LVEF < 35%) who received TAVR from 7 high-volume centers from June 2017 to May 2021. The inclusion and exclusion criteria are described above. 10 – 12 Patients with missing study data were excluded; the remaining patients were divided into three groups based on the LVEF and whether they received preventive ECMO: the ECMO + LVEF < 35% group; the non-ECMO + LVEF 35% group. This study complied with the Declaration of Helsinki and was approved by the local ethical commission. All patients provided written informed consent for procedures and subsequent data collection. Procedures and ECMO ECMO was performed by the Medtronic ECMO system (Bioconsole 560, Medtronic, Minneapolis, MN, USA). It comprises a centrifugal pump, membrane oxygenator, coated pipeline, and coated peripheral arteriovenous cannula. The pre-filled solution was 1000 mL sodium lactate Ringer's solution (Shijiazhuang Siyao Co., LTD., Shijiazhuang, Hebei, China). The femoral artery and femoral vein were intubated, and a whole-blood activated clotting time > 220 s was used to start ECMO-assisted circulation (2.5–3.0 L/min). The nasopharyngeal temperature was dropped to about 34℃. After the hemodynamics were stable, the nasopharyngeal temperature was rewarmed to about 37℃, the flow rate was gradually reduced, and the machine was then withdrawn. End points and definition According to the Valvular Academic Research Consortium-3 criteria, 13 the primary end point was 2-year all-cause mortality. Secondary end points were 2-year composite end points that included ECMO withdrawal failure, cardiovascular events or rehospitalization due to heart failure, and compound adverse events. Complex adverse events were defined as a combination of stroke, hemolysis, distal limb ischemia, bleeding at the ECMO site or gastrointestinal bleeding, and acute kidney injury. The main diagnosis of ECMO was determined using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code. 14 Associated organ failure during ECMO support, was also classified according to the ICD-10-CM code. Data collection Demographic, anthropometric, and medical history data were collected at baseline. Multidetector computed tomography, laboratory, and echocardiographic parameters were measured before the ECMO system was implanted. In addition, the in-hospital management data, information about the procedure, and the planned clinical follow-up (1, 12 and 24 months) data were collected. Procedural steps were as described previously. 10 – 12 Follow-up with the patient was conducted through clinical visits and/or telephone contact after a predetermined time point. Statistical analyses Continuous variables subject to normal distribution were reported as mean ± standard deviation, and variance analysis was used to test differences between groups. If continuous variables were not normally distributed, the median (interquartile range) was reported, and the Mann-Whitney U-test was used to test differences between groups. Categorical variables were reported as frequency (percentage); differences between groups were compared using the Chi-square or the Fisher precision tests, if applicable. The differences among the three groups were compared pairwise; the Bonferroni method was used for multiple test correction; and the adjusted P value was obtained. The multivariate logistic regression model included statistically significant variables from univariate logistic regression analysis. Logistic regression analysis results were expressed as odds ratios (OR) and 95% confidence intervals (CI). For survival data, the Kaplan-Meier curve was used to describe the survival rate of each group, and the log-rank test was used to compare the differences in the distribution of survival curves among the groups. Multivariate Cox proportional hazard regression analysis was used to explore the factors influencing survival outcomes. Statistically significant variables in univariate Cox regression analysis were included in the model, and the analysis results were expressed as hazard ratios (HR) and 95% CIs. In addition, inverse probabilistic treatment weighting (IPTW) based on the covariate balance propensity score (CBPS) was used to adjust for confounding factors between treatment (different LVEF groups) and survival outcomes. The CBPS model included the statistically significant variables in the univariate Cox regression analysis. All analyses were performed using R 4.3.0 (R Foundation, Vienna, Austria). For all the preceding tests, bilateral P values < 0.05 were considered statistically significant. Results Baseline characteristics and periprocedural outcomes Of the total 751 patients, 51 (6.8%), 38 (5.1%), and 662 (88.1%) patients were divided into the (i) ECMO + LVEF < 35% group, (ii) the non-ECMO + LVEF 35% group, respectively (Fig. 1 ). The baseline characteristics are shown in Table 1 . Compared with the non-ECMO + LVEF > 35% group, patients in the ECMO + LVEF < 35% group had a higher Society of Thoracic Surgeons score [8.9 (7.4–10.0)% vs. 5.4 (3.8–7.3)%] and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II score [10.2 (8.4–11.1)% vs. 5.2 (3.7–8.2)%] (all P < 0.001). Table 1 Baseline Demographic Characteristics Low LVEF with ECMO group (n = 51) Low LVEF without ECMO group (n = 38) P value Normal LVEF group (n = 662) P value Low LVEF with ECMO vs. Low LVEF without ECMO group Normal LVEF vs. Low LVEF with ECMO group Normal LVEF vs. Low LVEF without ECMO group Age, years 73.0 (67.5–79.0) 73.5 (66.0–80.0) 1.000 72.0 (66.0–78.0) 1.000 0.735 Male, % 82.4 (42) 78.9 (30) 1.000 71.0 (470) 0.345 1.000 BMI, kg/m 2 22.4 (19.0–24.8) 22.4 (19.8–25.0) 1.000 23.1 (20.2–26.1) 0.054 0.246 NYHA functional class ≥ II, % 98.0 (50) 100.0 (38) 1.000 96.1 (636) 1.000 1.000 STS risk score, % 8.9 (7.4–10.0) 8.4 (6.8–10.5) 1.000 5.4 (3.8–7.3) < 0.001 0.264 EuroSCORE II, % 10.2 (8.4–11.1) 9.5 (7.8–11.2) 1.000 5.2 (3.7–8.2) < 0.001 0.162 Diabetes mellitus, % 37.3 (19) 36.8 (14) 1.000 20.1 (133) 0.021 0.072 Hypertension, % 86.3 (44) 76.3 (29) 1.000 61.8 (409) < 0.001 0.312 Dyslipidemia, % 41.2 (21) 39.5 (15) 1.000 23.7 (157) 0.027 0.135 Peripheral artery disease, % 49.0 (25) 42.1 (16) 1.000 36.6 (242) 0.315 1.000 Cerebrovascular disease, % 3.9 (2) 0 (0) 1.000 2.9 (19) 1.000 1.000 Coronary artery disease, % 41.2 (21) 42.1 (16) 1.000 26.6 (176) 0.111 0.174 Previous PCI, % 5.9 (3) 5.3 (2) 1.000 2.6 (17) 0.498 0.828 Previous CABG, % 3.9 (2) 7.9 (3) 1.000 2.4 (16) 1.000 0.234 Atrial fi brillation 29.4 (15) 26.3 (10) 1.000 23.1 (153) 1.000 1.000 Permanent pacemaker implant, % 9.8 (5) 2.6 (1) 0.699 3.2 (21) 0.096 1.000 NT-proBNP, pg/mL 1677.0 (869.0–2359.0) 1382.5 (717.0–2266.0) 1.000 1982.5 (1338.0–2719.0) 0.105 0.030 BMI indicates body mass index; CABG, coronary artery bypass graft; COPD, chronic obstructive pulmonary disease; EuroSCORE, European System for Cardiac Operative Risk Evaluation; NT-proBNP, N-terminal pro-brain natriuretic peptide; NYHA, New York Heart Association; PCI, percutaneous coronary intervention; STS, Society of Thoracic Surgeons. Table 2 shows the preprocedural imaging assessment results. The LVEFs of the ECMO + LVEF < 35% group, the non-ECMO + LVEF 35% group were 26.0 (24.0–32.0)%, 33.0 (30.0–34.0)%, and 52.0 (48.0–57.0)%, respectively. Notably, systolic pulmonary artery pressure was significantly higher in patients with LVEF 35% group (all P < 0.001). In addition, there were no significant differences in preprocedural imaging characteristics among the three groups, except for slight differences in bicuspid aortic valve, sinotubular junction, and ascending aorta diameter. Table 2 Baseline Echocardiography and Computed Tomography Characteristics Low LVEF with ECMO group (n = 51) Low LVEF without ECMO group (n = 38) P Value Normal LVEF group (n = 662) P value Low LVEF with ECMO vs. Low LVEF without ECMO group Normal LVEF vs. Low LVEF with ECMO group Normal LVEF vs. Low LVEF without ECMO group Preoperative transthoracic echocardiography LVEF, % 26.0 (24.0–32.0) 33.0 (30.0–34.0) < 0.001 52.0 (48.0–57.0) < 0.001 < 0.001 Bicuspid aortic valve, % 11.8 (6) 18.4 (7) 1.000 6.2 (41) 0.411 0.033 Mean PG, mmHg 5.1 (2.4–6.6) 4.4 (3.0–6.5) 1.000 4.9 (3.5–6.2) 1.000 1.000 Mitral regurgitation ≥ moderate, % 29.4 (15) 34.2 (13) 1.000 24.3 (161) 1.000 0.714 Preoperative computed tomography angiography Annulus diameter, mm 26.5 (25.1–28.0) 27.0 (25.9–28.5) 1.000 27.6 (25.8–28.7) 0.129 0.843 LVOT diameter, mm 29.2 (27.8–31.1) 29.0 (26.7– 30.2) 0.399 29.2 (27.3–30.5) 1.000 0.663 AA diameter, mm 42.6 (40.5– 45.4) 41.9 (38.7–43.6) 0.378 41.2 (39.2–43.5) 0.021 1.000 Aorta angle, degree 50.0 (42.0–55.5) 49.0 (45.0–55.0) 1.000 47.0 (39.0–52.0) 0.081 0.069 AA indicates ascending aorta; AV, aortic valve; LVEF, left ventricular ejection fraction; LVOT, left ventricular outflow tract; PG, pressure gradient; STJ, sinotubular junction. Procedural and in-hospital outcomes are shown in Table 3 . A total of 644 patients (85.8%) had the transapical approach, and 69 patients (9.2%) had the transfemoral artery approach. Additionally, 38 patients (5.0%) were chosen alternative approaches decided by surgeons due to cardiac anatomical incompatibility or severe peripheral vascular calcification/stenosis. There were no statistically significant differences between the three groups in procedural parameters and in the incidence of major periprocedural complications. Table 3 Intraprocedural and Hospitalization Outcomes Low LVEF with ECMO group (n = 51) Low LVEF without ECMO group (n = 38) P value Normal LVEF group (n = 662) P value Low LVEF with ECMO vs. Low LVEF without ECMO group Normal LVEF vs. Low LVEF with ECMO group Normal LVEF vs. Low LVEF without ECMO group Intraprocedural outcomes Approach Transapical, % 90.2 (46) 94.7 (36) 1.000 84.9 (562) 1.000 0.453 Transfemoral artery, % 7.8 (4) 5.3 (2) 1.000 9.5 (63) 1.000 1.000 Other, % 2.0 (1) 0 (0) 1.000 5.1 (34) 1.000 0.747 Implanted valve oversizing, % 3.9 (2) 10.5 (4) 1.000 6.5 (43) 1.000 0.939 Postprocedural outcomes Procedural success, % 94.1 (48) 97.4 (37) 1.000 97.1 (643) 0.609 1.000 Conversion to open heart surgery, % 3.9 (2) 0 (0) 1.000 1.7 (11) 0.711 1.000 Valve-in-valve implant, % 0 (0) 0 (0) N/A 0.2 (1) N/A N/A DSA, digital subtracted angiography. Clinical outcomes ECMO + LVEF < 35% group vs. non-ECMO + LVEF 35% group . The 2-year all-cause mortality in the three groups was 11.8%, 23.7%, and 14.8%, respectively (all P > 0.05) (Fig. 2 A). The 2-year composite end points for the groups are shown in Fig. 2 B. Compared with the non-ECMO + LVEF > 35% group, the ECMO + LVEF < 35% group (HR = 2.27, 95% CI: 1.45–3.56, P < 0.001) and the non-ECMO + LVEF < 35% group (HR = 2.43, 95% CI: 1.47–4.01, P < 0.001) had worse outcomes. In the weighted univariate Cox model, the ECMO + LVEF < 35% group was associated with an increased incidence of 2-year composite end points (HR: 2.50; 95% CI: 1.52–4.11) (Fig. 2 C). LVEF 35% group. As expected, the 2-year all-cause mortality in patients with LVEF 35% (HR: 1.18; 95% CI: 0.69–2.03, P = 0.547), and the 2-year composite end points were worse (HR: 2.34; 95% CI: 1.64–3.33, P < 0.001) (Figs. 3 A, 3 B). The logistic regression analysis results of these two groups are shown in Table 4 . The results of the multivariate analysis showed that the Society of Thoracic Surgeons score, the EuroSCORE II, hypertension, NTproBNP levels, and the systolic pulmonary artery pressure were risk factors. Table 4 Logistic Regression Analysis Between LVEF 35% Subgroup Variables Univariable Analysis Multivariable Analysis OR ratio 95% CI P value OR ratio 95% CI P value BMI 0.90 0.84–0.96 0.002 STS risk score 3.11 3.03–3.20 < 0.001 2.13 1.05–3.30 < 0.001 EuroSCORE II 3.13 3.06–3.21 < 0.001 2.52 1.31–3.68 < 0.001 Diabetes mellitus 2.34 1.45–3.73 0.001 Hypertension 2.82 1.65–5.12 < 0.001 3.32 1.85–4.58 0.001 NTproBNP 2.21 1.79–3.31 < 0.001 3.14 1.20–5.93 0.001 Pulmonary systolic artery pressure 3.23 1.40–4.93 < 0.001 1.57 1.02–1.74 0.002 STJ diameter 0.89 0.84–0.95 < 0.001 AA diameter 1.08 1.01–1.16 0.029 Aorta angle 1.04 1.01–1.07 0.004 ECMO + LVEF < 35% group vs. non-ECMO + LVEF < 35% group. The 2-year all-cause mortality was lower in the ECMO + LVEF < 35% group than in the non-ECMO + LVEF < 35% group (HR: 0.47; 95% CI: 0.17–0.82, P = 0.042), and the incidence of the 2-year composite end points was similar (HR: 0.94; 95% CI: 0.50–1.78, P = 0.858) (Figs. 3 C, 3 D). LVEF improvement The LVEF values in the ECMO + LVEF < 35% group, the non-ECMO + LVEF 35% group were similar at the 2-year follow-up [48.0 (43.5–54.0)% vs. 50.0 (47.0–54.0)% vs. 57.0 (52.0–60.0)%] ( Supplemental Fig. 1A ). Notably, the difference in LVEF values between the two LVEF 35% group was also significantly reduced [24.8 (18.6–29.0)% vs. 9.4 (6.2–12.3)%; 19.7 (15.5–24.2)% vs. 8.0 (4.7–11.5)%, all P < 0.001] ( Supplemental Fig. 1B ). The results of the subgroup analyses of the LVEF 35% group are shown in Supplemental Fig. 1C and 1D . Discussion The main findings of this study are as follows: (i) The LVEF of patients with severe heart failure improved significantly after the procedures, reaching 49.0 (45.0–53.0)% at the 2-year follow-up. (ii) The 2-year clinical outcomes of patients with LVEF < 35% were similar to those of patients with normal LVEF function. (iii) The primary end points in the ECMO + LVEF < 35% group were better than those in the non-ECMO + LVEF < 35% group. Aortic regurgitation is one of the most common heart valve diseases, and the natural prognosis of patients with chronic severe AR with symptoms is usually very poor. 15 Currently, the guidelines recommend SAVR as the preferred treatment for pure AR. 10,11 However, due to advanced age and severe comorbidities, most patients may not tolerate the operation. 16 TAVR, as a new minimally invasive interventional therapy for severe AS, is of great significance especially for patients with severe heart failure who would have difficulty tolerating SAVR. 1 , 2 In recent years, study results have preliminarily confirmed that TAVR can yield significant clinical effects in the treatment of pure AR. 17 However, whether patients with a low LVEF can undergo TAVR and achieve comparable prognostic outcomes remains unclear. Our study is the first to date to evaluate the prognostic significance of TAVR and the clinical value of ECMO in this population. Previous studies have shown that LVEF generally improves substantially after the procedure. 6 , 18 In particular, Baron et al. found that patients with severe left ventricular dysfunction benefited more from TAVR than patients with left ventricular function retention. 19 Similarly, our findings show that patients with a low LVEF did not exhibit periprocedural outcomes compared to patients with normal LVEF function at baseline and that the LVEF at the 2-year follow-up was evenly approximated. Meanwhile, the difference between the two populations was significantly reduced [22.9 (17.5–26.3)% vs. 8.6 (5.5–12.0)%, P < 0.001]. These results suggested that patients with a low LVEF and pure AR should not be denied TAVR based on whether the LVEF is dysfunctional. In addition, the current conventional short-term circulation auxiliary methods mainly include ECLS, ECMO, and intra-aortic balloon pump counterpulsation, all of which can theoretically be applied as circulation auxiliary methods during TAVR. However, in clinical applications, due to the counterpulsation, the balloon needs to be placed in the descending aorta, which may affect the procedural process, so there are few reports about the application of the intra-aortic balloon pump in TAVR. When severe complications affecting circulatory stability occur during the procedure or conversion to SAVR is required, ECLS can be used urgently to complete the operation or to manage related complications under cardiopulmonary bypass. 7 It is worth noting that the advantages of ECMO applied to TAVR lie mainly in its small volume of precharge, a low degree of heparinization, and relatively few complications; thus it can be prioritized as a circulatory auxiliary means for preventive applications. 20 The results of this study showed that the 2-year all-cause mortality was lower in patients undergoing ECMO assistance than in patients without ECMO assistance. However, the 2-year composite end points in the ECMO + LVEF < 35% group and the non-ECMO + LVEF < 35% group were similar, suggesting that the net clinical benefit for patients with severe heart failure in this study is questionable. The study has the following limitations: First, this study was a multicenter prospective study, but data for 167 patients (22.2%) were collected retrospectively. Second, this study lacked an independent core laboratory to analyze the results of medical images and independent events, which may have led to certain errors. Third, the sample sizes in both the ECMO + LVEF < 35% group and the non-ECMO + LVEF < 35% group were relatively small, so the clinical outcomes should be interpreted with caution. Fourth, our study was based on evaluation of the prognostic effect after TAVR, so we did not evaluate the diversion time and flow rate of ECMO. Finally, this is a study on a Chinese population, and the preceding factors may affect the further application of the findings in other populations. Conclusions TAVR is feasible in patients with pure AR with a low LVEF. The clinical outcome is similar to that of patients with normal LVEF function, with a significant improvement in LVEF at the 2-year follow-up. Importantly, patients with an LVEF < 35% who received ECMO assistance had a better survival rate than patients without ECMO assistance. These findings continue to support the fact that such patients should not be denied TAVR because they have LVEF dysfunction. Especially for patients with a low LVEF, implanting ECMO in a timely manner has potential therapeutic benefits. Abbreviations AR aortic regurgitation CBPS covariate balance propensity score CI confidence intervals ECLS extracorporeal life support ECMO extracorporeal membrane oxygenation IPTW inverse probabilistic treatment weighting LVEF left ventricular ejection fraction OR odds ratio SAVR surgical aortic valve replacement TAVR transcatheter aortic valve replacement Declarations Ethics approval and consent to participate The protocol was approved by the ethics committee of Xijing Hospital (approval number: KY-20192138-C-1) and ClinicalTrials.gov Protocol Registration System (NCT02917980). All human participants provided informed consent prior to enrollment in this study. Consent for publication All authors have read and approved the final version of the manuscript, agreed to its publication, and authorized the corresponding author, Yang Jian, to handle all related publication matters. Availability of data and materials The original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author. Competing Interests The authors have no conflicts of interest to declare. Funding This work was supported by the Development and Transformation of New Technology and Construction of Precision Diagnosis and Treatment System for Transcatheter Interventional Diagnosis and Treatment of Structural Heart Diseases (2022YFC2503400); Research on Key Techniques of Minimally Invasive Treatment for Valvular Heart Diseases (2023-YBSF-105). Authors' contributions Jian Yang and Yang Liu led the conceptualization and design of the study; Yu Mao, Menggen Zhai, and Ping Jin were responsible for collecting data from the multicenter clinical study; Wenjing Li conducted the formal analysis and statistical processing of the study data; Jian Yang and Gejun Zhang spearheaded the application and acquisition of research funding; Haibo Zhang and Jian Liu participated in the field investigations and clinical implementation of the study; Jian Yang and Yu Mao collaboratively designed and optimized the study methodology; Yang Liu and Ping Jin undertook project management and process coordination for the study; Gejun Zhang, Haibo Zhang, and Jian Liu provided critical clinical resources and technical support for the study’s execution; Jian Yang, as the corresponding author, oversaw the overall supervision and academic guidance throughout the study. The initial draft of the manuscript was prepared by Yu Mao, followed by joint review, revision, and refinement by all authors. All authors participated in the verification of study data and results, and collectively bear responsibility for the authenticity and integrity of the study content. Acknowledgements We would like to thank Protext Editorial Services, USA, for English language editing. References Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 2019; 380: 1695-705. Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med 2019; 380: 1706-15. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation 2005; 112: 125-34. Arora S, Lahewala S, Zuzek Z, et al. Transcatheter aortic valve replacement in aortic regurgitation: The U.S. experience. Catheter Cardiovasc Interv 2021; 98: E153-62. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011; 364: 2187-98. Maes F, Lerakis S, Barbosa RH, et al. Outcomes from transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis and left ventricular ejection fraction less than 30%: a substudy from the TOPAS-TAVI registry. JAMA Cardiol 2019; 4: 64-70. Higuchi R. Tobaru T, Hagiya K, et al. Outcomes of patients requiring extracorporeal membrane oxygenation in transcatheter aortic valve implantation: a clinical case series. Heart Vessels 2018; 33: 1343-9. Stewart GC, Givertz MM. Mechanical circulatory support for advanced heart failure: patients and technology in evolution. Circulation 2012; 125: 1304-15. Takeda K, Garan AR, Ando M, et al. 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Increased mortality after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and low ejection fraction: a meta-analysis of 6898 patients. Int J Cardiol 2014; 176: 32-9. Baron SJ, Arnold SV, Herrmann HC, et al. Impact of ejection fraction and aortic valve gradient on outcomes of transcatheter aortic valve replacement. J Am Coll Cardiol 2016; 67: 23492358. Drews T, Pasic M, Buz S, et al. Elective use of femoro-femoral cardiopulmonary bypass during transcatheter aortic valve implantation. Eur J Cardiothorac Surg 2015; 47: 24-30; discussion Additional Declarations No competing interests reported. Supplementary Files SupplementalMaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 10 Apr, 2026 Reviewers agreed at journal 04 Apr, 2026 Reviewers invited by journal 02 Apr, 2026 Editor assigned by journal 31 Mar, 2026 Editor invited by journal 10 Mar, 2026 Submission checks completed at journal 10 Mar, 2026 First submitted to journal 10 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8976112","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617547846,"identity":"09df8dac-fc2c-4cce-ab4d-b823e52be915","order_by":0,"name":"Yu Mao","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Mao","suffix":""},{"id":617547847,"identity":"f0cfeb87-90c8-432b-a0f0-436bd807ecae","order_by":1,"name":"Mengen Zhai","email":"","orcid":"","institution":"Xijing Hospital, Air Force Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mengen","middleName":"","lastName":"Zhai","suffix":""},{"id":617547848,"identity":"85ec0ea7-ba04-49d0-ad70-51512f2d721e","order_by":2,"name":"Ping Jin","email":"","orcid":"","institution":"Xijing Hospital, Air Force Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ping","middleName":"","lastName":"Jin","suffix":""},{"id":617547849,"identity":"51137b09-5b1d-4d5d-b18e-d9e0ea952b0f","order_by":3,"name":"Wenjing Li","email":"","orcid":"","institution":"MAKE medical technology Co. Ltd","correspondingAuthor":false,"prefix":"","firstName":"Wenjing","middleName":"","lastName":"Li","suffix":""},{"id":617547850,"identity":"fbc61424-50d4-45aa-9f72-818863268bcc","order_by":4,"name":"Gejun Zhang","email":"","orcid":"","institution":"Fuwai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gejun","middleName":"","lastName":"Zhang","suffix":""},{"id":617547852,"identity":"bb84f7fd-3fa1-405c-a79d-56af47241422","order_by":5,"name":"Haibo Zhang","email":"","orcid":"","institution":"Beijing Anzhen Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haibo","middleName":"","lastName":"Zhang","suffix":""},{"id":617547853,"identity":"9bf0e147-2266-41d8-b7fb-d133da7a906e","order_by":6,"name":"Jian Liu","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jian","middleName":"","lastName":"Liu","suffix":""},{"id":617547864,"identity":"f2122f49-497a-4881-a884-d64374ef84c0","order_by":7,"name":"Yang Liu","email":"","orcid":"","institution":"Xijing Hospital, Air Force Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Liu","suffix":""},{"id":617547866,"identity":"81a005a8-9958-4fe9-bc0b-55d13ebac468","order_by":8,"name":"Jian Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDklEQVRIiWNgGAWjYLACCQMGBjb2xsYHHxtAXMbGA0Rp4eM53Gw4s4FBAqilgbAWEJCTSG+T5gVrYWDAq8Xg+NnDLywK7PLYGBIbpG132NTpth8G2lJjE41Ty5m8NAsJg+RiNoaDDca5Z9IkzM4kArUcS8ttwKXlQI6ZgYQBc2IbY2NDcm7bYQmzA0AtjA2HcWs5/wakpT6xjRmozBKk5fxDAlpu5Bg/kDA4nNjGxtjYzAjScoOALZI33pgBA/l4YhsPYzNjb1ua5LYbQFsS8PiF73yO8WeJP9WJ8+c/f/7jZ5sNv9n59IcPPtTY4NSicICBTVoCQzgBh3IQkG9gYP74AY+CUTAKRsEoGAUMAMndZVXq8kXUAAAAAElFTkSuQmCC","orcid":"","institution":"Xijing Hospital, Air Force Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jian","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2026-02-26 09:39:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8976112/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8976112/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106469218,"identity":"39e1a2ed-786c-4424-a0fc-71b38db11e8a","added_by":"auto","created_at":"2026-04-09 00:51:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2106515,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow chart.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with pure aortic regurgitation with low left ventricular ejection fraction who underwent transcatheter aortic valve replacement at 7 institutions from June 2017 and May 2021 were enrolled.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8976112/v1/4c87be6e052c9a22c2960e7e.png"},{"id":106469219,"identity":"140911d4-7e95-4b96-a648-8db938abec9e","added_by":"auto","created_at":"2026-04-09 00:51:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":846984,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier and Cox Regression Analysis.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKaplan-Meier analysis of \u003cstrong\u003eA\u003c/strong\u003e all-cause death and \u003cstrong\u003eB\u003c/strong\u003e composite end points at 2 years among three groups. \u003cstrong\u003eC\u003c/strong\u003e In the weighted univariate Cox model, the model was inverse probability of treatment weighted.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8976112/v1/c4ea4b073bbd17b1116f2526.png"},{"id":106469221,"identity":"a296576c-7724-4409-a8f0-6f3c47889ad3","added_by":"auto","created_at":"2026-04-09 00:51:21","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2019261,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier Analysis.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKaplan-Meier analysis at 2 years between the subgroups. \u003cstrong\u003eA\u003c/strong\u003e Kaplan-Meier curves of 2-year all-cause mortality and \u003cstrong\u003eB\u003c/strong\u003e composite end points between the left ventricular ejection fraction \u0026lt; 35% subgroup and the left ventricular ejection fraction \u0026gt; 35% subgroup. \u003cstrong\u003eC\u003c/strong\u003e Kaplan-Meier curves of 2-year all-cause mortality and \u003cstrong\u003eD\u003c/strong\u003e composite end points between the ECMO + LVEF \u0026lt; 35% group and the non-ECMO + LVEF \u0026lt; 35% group\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8976112/v1/af0e136f43d804174b38d538.png"},{"id":106959525,"identity":"a2ae14f8-86a5-45c0-a1da-d16bdcfccc39","added_by":"auto","created_at":"2026-04-15 09:11:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5850905,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8976112/v1/4182da0a-fb9d-4504-bb22-7a576697b256.pdf"},{"id":106724248,"identity":"c31fc17b-ae69-4cc0-9747-35dc231b4243","added_by":"auto","created_at":"2026-04-12 18:26:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":302274,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-8976112/v1/2dc6ab7ab0b631482993166b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"TAVR in Patients with Aortic Regurgitation with Low LVEF: Clinical Outcomes and the Value of ECMO","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTranscatheter aortic valve replacement (TAVR) has been recognized as an effective alternative to surgical aortic valve replacement (SAVR) in the treatment of aortic stenosis (AS).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Aortic regurgitant (AR) is a common aortic valve disease, and patients with symptomatic chronic severe AR have a poorer prognosis.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Preliminary studies have shown the safety and effectiveness of TAVR for such patients with high surgical risk.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Furthermore, some patients with AR also have severe left cardiac dysfunction. However, in TAVR for patients with severe AS, a left ventricular ejection fraction (LVEF)\u0026thinsp;\u0026lt;\u0026thinsp;20% was used as the exclusion item.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Previous studies have shown that TAVR could significantly improve the postprocedural LVEF and the prognosis.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e However, few studies have been reported for patients with pure AR with low LVEF. In addition, the application of an extracorporeal life support (ECLS) system in the periprocedural cardiopulmonary function protection is an effective strategy for such patients.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e In particular, extracorporeal membrane oxygenation (ECMO), as a non-sedating, non-intubating cardiopulmonary support technique, may provide stable hemodynamic support during the periprocedural period.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Therefore, the goal of this study was to evaluate the clinical outcomes of TAVR in patients with pure AR with an LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% as well as the clinical value of ECMO.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population and design\u003c/h2\u003e \u003cp\u003eThis study prospectively collected 751 patients with pure AR combined with severe heart failure (LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35%) who received TAVR from 7 high-volume centers from June 2017 to May 2021. The inclusion and exclusion criteria are described above.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Patients with missing study data were excluded; the remaining patients were divided into three groups based on the LVEF and whether they received preventive ECMO: the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group; the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group; and the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group. This study complied with the Declaration of Helsinki and was approved by the local ethical commission. All patients provided written informed consent for procedures and subsequent data collection.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedures and ECMO\u003c/h3\u003e\n\u003cp\u003eECMO was performed by the Medtronic ECMO system (Bioconsole 560, Medtronic, Minneapolis, MN, USA). It comprises a centrifugal pump, membrane oxygenator, coated pipeline, and coated peripheral arteriovenous cannula. The pre-filled solution was 1000 mL sodium lactate Ringer's solution (Shijiazhuang Siyao Co., LTD., Shijiazhuang, Hebei, China). The femoral artery and femoral vein were intubated, and a whole-blood activated clotting time\u0026thinsp;\u0026gt;\u0026thinsp;220 s was used to start ECMO-assisted circulation (2.5\u0026ndash;3.0 L/min). The nasopharyngeal temperature was dropped to about 34℃. After the hemodynamics were stable, the nasopharyngeal temperature was rewarmed to about 37℃, the flow rate was gradually reduced, and the machine was then withdrawn.\u003c/p\u003e\n\u003ch3\u003eEnd points and definition\u003c/h3\u003e\n\u003cp\u003eAccording to the Valvular Academic Research Consortium-3 criteria,\u003csup\u003e13\u003c/sup\u003e the primary end point was 2-year all-cause mortality. Secondary end points were 2-year composite end points that included ECMO withdrawal failure, cardiovascular events or rehospitalization due to heart failure, and compound adverse events. Complex adverse events were defined as a combination of stroke, hemolysis, distal limb ischemia, bleeding at the ECMO site or gastrointestinal bleeding, and acute kidney injury. The main diagnosis of ECMO was determined using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Associated organ failure during ECMO support, was also classified according to the ICD-10-CM code.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eDemographic, anthropometric, and medical history data were collected at baseline. Multidetector computed tomography, laboratory, and echocardiographic parameters were measured before the ECMO system was implanted. In addition, the in-hospital management data, information about the procedure, and the planned clinical follow-up (1, 12 and 24 months) data were collected. Procedural steps were as described previously.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Follow-up with the patient was conducted through clinical visits and/or telephone contact after a predetermined time point.\u003c/p\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eContinuous variables subject to normal distribution were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and variance analysis was used to test differences between groups. If continuous variables were not normally distributed, the median (interquartile range) was reported, and the Mann-Whitney U-test was used to test differences between groups. Categorical variables were reported as frequency (percentage); differences between groups were compared using the Chi-square or the Fisher precision tests, if applicable. The differences among the three groups were compared pairwise; the Bonferroni method was used for multiple test correction; and the adjusted \u003cem\u003eP\u003c/em\u003e value was obtained.\u003c/p\u003e \u003cp\u003eThe multivariate logistic regression model included statistically significant variables from univariate logistic regression analysis. Logistic regression analysis results were expressed as odds ratios (OR) and 95% confidence intervals (CI).\u003c/p\u003e \u003cp\u003eFor survival data, the Kaplan-Meier curve was used to describe the survival rate of each group, and the log-rank test was used to compare the differences in the distribution of survival curves among the groups. Multivariate Cox proportional hazard regression analysis was used to explore the factors influencing survival outcomes. Statistically significant variables in univariate Cox regression analysis were included in the model, and the analysis results were expressed as hazard ratios (HR) and 95% CIs.\u003c/p\u003e \u003cp\u003eIn addition, inverse probabilistic treatment weighting (IPTW) based on the covariate balance propensity score (CBPS) was used to adjust for confounding factors between treatment (different LVEF groups) and survival outcomes. The CBPS model included the statistically significant variables in the univariate Cox regression analysis.\u003c/p\u003e \u003cp\u003eAll analyses were performed using R 4.3.0 (R Foundation, Vienna, Austria). For all the preceding tests, bilateral \u003cem\u003eP\u003c/em\u003e values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics and periprocedural outcomes\u003c/h2\u003e \u003cp\u003eOf the total 751 patients, 51 (6.8%), 38 (5.1%), and 662 (88.1%) patients were divided into the (i) ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group, (ii) the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group, and (iii) the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The baseline characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Compared with the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group, patients in the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group had a higher Society of Thoracic Surgeons score [8.9 (7.4\u0026ndash;10.0)% vs. 5.4 (3.8\u0026ndash;7.3)%] and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II score [10.2 (8.4\u0026ndash;11.1)% vs. 5.2 (3.7\u0026ndash;8.2)%] (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Demographic Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLow LVEF with ECMO group (n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLow LVEF without ECMO group (n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNormal LVEF group (n\u0026thinsp;=\u0026thinsp;662)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow LVEF with ECMO vs. Low LVEF without ECMO group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNormal LVEF vs. Low LVEF with ECMO group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNormal LVEF vs. Low LVEF without ECMO group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73.0 (67.5\u0026ndash;79.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.5 (66.0\u0026ndash;80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e72.0 (66.0\u0026ndash;78.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82.4 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.9 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e71.0 (470)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.4 (19.0\u0026ndash;24.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.4 (19.8\u0026ndash;25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.1 (20.2\u0026ndash;26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNYHA functional class\u0026thinsp;\u0026ge;\u0026thinsp;II, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98.0 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e96.1 (636)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTS risk score, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.9 (7.4\u0026ndash;10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.4 (6.8\u0026ndash;10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.4 (3.8\u0026ndash;7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEuroSCORE II, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.2 (8.4\u0026ndash;11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.5 (7.8\u0026ndash;11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.2 (3.7\u0026ndash;8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.162\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37.3 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.8 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.1 (133)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86.3 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.3 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e61.8 (409)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.312\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidemia, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41.2 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.5 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.7 (157)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.027\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral artery disease, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49.0 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.1 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36.6 (242)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular disease, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.9 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.9 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary artery disease, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41.2 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.1 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.6 (176)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.174\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious PCI, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.9 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.3 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.6 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.828\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious CABG, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.9 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.9 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.4 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.234\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial \u003cspan fontcategory=\"NonProportional\" class=\"\" name=\"Emphasis\"\u003efi\u003c/span\u003e brillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.4 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.3 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.1 (153)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePermanent pacemaker implant, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.8 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.699\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.2 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNT-proBNP, pg/mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1677.0 (869.0\u0026ndash;2359.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1382.5 (717.0\u0026ndash;2266.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1982.5 (1338.0\u0026ndash;2719.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eBMI indicates body mass index; CABG, coronary artery bypass graft; COPD, chronic obstructive pulmonary disease; EuroSCORE, European System for Cardiac Operative Risk Evaluation; NT-proBNP, N-terminal pro-brain natriuretic peptide; NYHA, New York Heart Association; PCI, percutaneous coronary intervention; STS, Society of Thoracic Surgeons.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the preprocedural imaging assessment results. The LVEFs of the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group, the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group, and the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group were 26.0 (24.0\u0026ndash;32.0)%, 33.0 (30.0\u0026ndash;34.0)%, and 52.0 (48.0\u0026ndash;57.0)%, respectively. Notably, systolic pulmonary artery pressure was significantly higher in patients with LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% (n\u0026thinsp;=\u0026thinsp;89) than in the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In addition, there were no significant differences in preprocedural imaging characteristics among the three groups, except for slight differences in bicuspid aortic valve, sinotubular junction, and ascending aorta diameter.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Echocardiography and Computed Tomography Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLow LVEF with ECMO group (n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLow LVEF without ECMO group (n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNormal LVEF group (n\u0026thinsp;=\u0026thinsp;662)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow LVEF with ECMO vs. Low LVEF without ECMO group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNormal LVEF vs. Low LVEF with ECMO group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNormal LVEF vs. Low LVEF without ECMO group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative transthoracic echocardiography\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.0 (24.0\u0026ndash;32.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.0 (30.0\u0026ndash;34.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.0 (48.0\u0026ndash;57.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBicuspid aortic valve, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.8 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.4 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.2 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.411\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.033\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean PG, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.1 (2.4\u0026ndash;6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4 (3.0\u0026ndash;6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.9 (3.5\u0026ndash;6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitral regurgitation\u0026thinsp;\u0026ge;\u0026thinsp;moderate, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.4 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.2 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.3 (161)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.714\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative computed tomography angiography\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnnulus diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.5 (25.1\u0026ndash;28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.0 (25.9\u0026ndash;28.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.6 (25.8\u0026ndash;28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.843\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOT diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.2 (27.8\u0026ndash;31.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.0 (26.7\u0026ndash; 30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.399\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.2 (27.3\u0026ndash;30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.663\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAA diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.6 (40.5\u0026ndash; 45.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.9 (38.7\u0026ndash;43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.2 (39.2\u0026ndash;43.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAorta angle, degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.0 (42.0\u0026ndash;55.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.0 (45.0\u0026ndash;55.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.0 (39.0\u0026ndash;52.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eAA indicates ascending aorta; AV, aortic valve; LVEF, left ventricular ejection fraction; LVOT, left ventricular outflow tract; PG, pressure gradient; STJ, sinotubular junction.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eProcedural and in-hospital outcomes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. A total of 644 patients (85.8%) had the transapical approach, and 69 patients (9.2%) had the transfemoral artery approach. Additionally, 38 patients (5.0%) were chosen alternative approaches decided by surgeons due to cardiac anatomical incompatibility or severe peripheral vascular calcification/stenosis. There were no statistically significant differences between the three groups in procedural parameters and in the incidence of major periprocedural complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraprocedural and Hospitalization Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLow LVEF with ECMO group (n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLow LVEF without ECMO group (n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNormal LVEF group (n\u0026thinsp;=\u0026thinsp;662)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow LVEF with ECMO vs. Low LVEF without ECMO group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNormal LVEF vs. Low LVEF with ECMO group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNormal LVEF vs. Low LVEF without ECMO group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraprocedural outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eApproach\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransapical, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.2 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.7 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84.9 (562)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.453\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfemoral artery, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.8 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.3 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.5 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.1 (34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.747\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplanted valve oversizing, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.5 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.5 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostprocedural outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedural success, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94.1 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.4 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97.1 (643)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to open heart surgery, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.7 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.711\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValve-in-valve implant, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eDSA, digital subtracted angiography.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical outcomes\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group vs. non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group vs. non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group\u003c/b\u003e. The 2-year all-cause mortality in the three groups was 11.8%, 23.7%, and 14.8%, respectively (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). The 2-year composite end points for the groups are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB. Compared with the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group, the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group (HR\u0026thinsp;=\u0026thinsp;2.27, 95% CI: 1.45\u0026ndash;3.56, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group (HR\u0026thinsp;=\u0026thinsp;2.43, 95% CI: 1.47\u0026ndash;4.01, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) had worse outcomes. In the weighted univariate Cox model, the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group was associated with an increased incidence of 2-year composite end points (HR: 2.50; 95% CI: 1.52\u0026ndash;4.11) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eLVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group vs. LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group.\u003c/b\u003e As expected, the 2-year all-cause mortality in patients with LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% was similar to that in patients with LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% (HR: 1.18; 95% CI: 0.69\u0026ndash;2.03, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.547), and the 2-year composite end points were worse (HR: 2.34; 95% CI: 1.64\u0026ndash;3.33, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). The logistic regression analysis results of these two groups are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The results of the multivariate analysis showed that the Society of Thoracic Surgeons score, the EuroSCORE II, hypertension, NTproBNP levels, and the systolic pulmonary artery pressure were risk factors.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic Regression Analysis Between LVEF\u0026lt;35% Subgroup and LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% Subgroup\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnivariable Analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eMultivariable Analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.84\u0026ndash;0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTS risk score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.03\u0026ndash;3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.05\u0026ndash;3.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEuroSCORE II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.06\u0026ndash;3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.31\u0026ndash;3.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.45\u0026ndash;3.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.65\u0026ndash;5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.85\u0026ndash;4.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNTproBNP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.79\u0026ndash;3.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.20\u0026ndash;5.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary systolic artery pressure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.40\u0026ndash;4.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.02\u0026ndash;1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTJ diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.84\u0026ndash;0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAA diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.01\u0026ndash;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAorta angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.01\u0026ndash;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group vs. non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group.\u003c/b\u003e The 2-year all-cause mortality was lower in the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group than in the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group (HR: 0.47; 95% CI: 0.17\u0026ndash;0.82, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.042), and the incidence of the 2-year composite end points was similar (HR: 0.94; 95% CI: 0.50\u0026ndash;1.78, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.858) (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLVEF improvement\u003c/h2\u003e \u003cp\u003eThe LVEF values in the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group, the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group, and the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group were similar at the 2-year follow-up [48.0 (43.5\u0026ndash;54.0)% vs. 50.0 (47.0\u0026ndash;54.0)% vs. 57.0 (52.0\u0026ndash;60.0)%] (\u003cb\u003eSupplemental Fig.\u0026nbsp;1A\u003c/b\u003e). Notably, the difference in LVEF values between the two LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% groups and the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group was also significantly reduced [24.8 (18.6\u0026ndash;29.0)% vs. 9.4 (6.2\u0026ndash;12.3)%; 19.7 (15.5\u0026ndash;24.2)% vs. 8.0 (4.7\u0026ndash;11.5)%, all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001] (\u003cb\u003eSupplemental Fig.\u0026nbsp;1B\u003c/b\u003e). The results of the subgroup analyses of the LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group and the LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group are shown in \u003cb\u003eSupplemental Fig.\u0026nbsp;1C and 1D\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main findings of this study are as follows: (i) The LVEF of patients with severe heart failure improved significantly after the procedures, reaching 49.0 (45.0\u0026ndash;53.0)% at the 2-year follow-up. (ii) The 2-year clinical outcomes of patients with LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% were similar to those of patients with normal LVEF function. (iii) The primary end points in the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group were better than those in the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group.\u003c/p\u003e \u003cp\u003eAortic regurgitation is one of the most common heart valve diseases, and the natural prognosis of patients with chronic severe AR with symptoms is usually very poor.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Currently, the guidelines recommend SAVR as the preferred treatment for pure AR.\u003csup\u003e10,11\u003c/sup\u003e However, due to advanced age and severe comorbidities, most patients may not tolerate the operation.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e TAVR, as a new minimally invasive interventional therapy for severe AS, is of great significance especially for patients with severe heart failure who would have difficulty tolerating SAVR.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In recent years, study results have preliminarily confirmed that TAVR can yield significant clinical effects in the treatment of pure AR.\u003csup\u003e17\u003c/sup\u003e However, whether patients with a low LVEF can undergo TAVR and achieve comparable prognostic outcomes remains unclear.\u003c/p\u003e \u003cp\u003eOur study is the first to date to evaluate the prognostic significance of TAVR and the clinical value of ECMO in this population. Previous studies have shown that LVEF generally improves substantially after the procedure.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In particular, Baron et al. found that patients with severe left ventricular dysfunction benefited more from TAVR than patients with left ventricular function retention.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Similarly, our findings show that patients with a low LVEF did not exhibit periprocedural outcomes compared to patients with normal LVEF function at baseline and that the LVEF at the 2-year follow-up was evenly approximated. Meanwhile, the difference between the two populations was significantly reduced [22.9 (17.5\u0026ndash;26.3)% vs. 8.6 (5.5\u0026ndash;12.0)%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. These results suggested that patients with a low LVEF and pure AR should not be denied TAVR based on whether the LVEF is dysfunctional.\u003c/p\u003e \u003cp\u003eIn addition, the current conventional short-term circulation auxiliary methods mainly include ECLS, ECMO, and intra-aortic balloon pump counterpulsation, all of which can theoretically be applied as circulation auxiliary methods during TAVR. However, in clinical applications, due to the counterpulsation, the balloon needs to be placed in the descending aorta, which may affect the procedural process, so there are few reports about the application of the intra-aortic balloon pump in TAVR. When severe complications affecting circulatory stability occur during the procedure or conversion to SAVR is required, ECLS can be used urgently to complete the operation or to manage related complications under cardiopulmonary bypass.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e It is worth noting that the advantages of ECMO applied to TAVR lie mainly in its small volume of precharge, a low degree of heparinization, and relatively few complications; thus it can be prioritized as a circulatory auxiliary means for preventive applications.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e The results of this study showed that the 2-year all-cause mortality was lower in patients undergoing ECMO assistance than in patients without ECMO assistance. However, the 2-year composite end points in the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group and the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group were similar, suggesting that the net clinical benefit for patients with severe heart failure in this study is questionable.\u003c/p\u003e \u003cp\u003eThe study has the following limitations: First, this study was a multicenter prospective study, but data for 167 patients (22.2%) were collected retrospectively. Second, this study lacked an independent core laboratory to analyze the results of medical images and independent events, which may have led to certain errors. Third, the sample sizes in both the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group and the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group were relatively small, so the clinical outcomes should be interpreted with caution. Fourth, our study was based on evaluation of the prognostic effect after TAVR, so we did not evaluate the diversion time and flow rate of ECMO. Finally, this is a study on a Chinese population, and the preceding factors may affect the further application of the findings in other populations.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTAVR is feasible in patients with pure AR with a low LVEF. The clinical outcome is similar to that of patients with normal LVEF function, with a significant improvement in LVEF at the 2-year follow-up. Importantly, patients with an LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% who received ECMO assistance had a better survival rate than patients without ECMO assistance. These findings continue to support the fact that such patients should not be denied TAVR because they have LVEF dysfunction. Especially for patients with a low LVEF, implanting ECMO in a timely manner has potential therapeutic benefits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAR \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;aortic regurgitation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCBPS \u0026nbsp;covariate balance propensity score\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;confidence intervals\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eECLS \u0026nbsp;extracorporeal life support\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eECMO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;extracorporeal membrane oxygenation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIPTW \u0026nbsp;inverse probabilistic treatment weighting\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLVEF \u0026nbsp;left ventricular ejection fraction\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOR \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;odds ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSAVR \u0026nbsp;surgical aortic valve replacement\u003c/p\u003e\n\u003cp\u003eTAVR \u0026nbsp;transcatheter aortic valve replacement\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol was approved by the ethics committee of Xijing Hospital (approval number: KY-20192138-C-1) and ClinicalTrials.gov Protocol Registration System (NCT02917980).\u0026nbsp;All human participants provided informed consent prior to enrollment in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final version of the manuscript, agreed to its publication, and authorized the corresponding author, Yang Jian, to handle all related publication matters.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Development and Transformation of New Technology and Construction of Precision Diagnosis and Treatment System for Transcatheter Interventional Diagnosis and Treatment of Structural Heart Diseases (2022YFC2503400); Research on Key Techniques of Minimally Invasive Treatment for Valvular Heart Diseases (2023-YBSF-105).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJian Yang and Yang Liu led the conceptualization and design of the study; Yu Mao, Menggen Zhai, and Ping Jin were responsible for collecting data from the multicenter clinical study; Wenjing Li conducted the formal analysis and statistical processing of the study data; Jian Yang and Gejun Zhang spearheaded the application and acquisition of research funding; Haibo Zhang and Jian Liu participated in the field investigations and clinical implementation of the study; Jian Yang and Yu Mao collaboratively designed and optimized the study methodology; Yang Liu and Ping Jin undertook project management and process coordination for the study; Gejun Zhang, Haibo Zhang, and Jian Liu provided critical clinical resources and technical support for the study’s execution; Jian Yang, as the corresponding author, oversaw the overall supervision and academic guidance throughout the study. The initial draft of the manuscript was prepared by Yu Mao, followed by joint review, revision, and refinement by all authors. All authors participated in the verification of study data and results, and collectively bear responsibility for the authenticity and integrity of the study content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Protext Editorial Services, USA, for English language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 2019; 380: 1695-705.\u003c/li\u003e\n\u003cli\u003ePopma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med 2019; 380: 1706-15.\u003c/li\u003e\n\u003cli\u003eBekeredjian R, Grayburn PA. 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Eur Heart J 2003; 24: 1231-43.\u003c/li\u003e\n\u003cli\u003eRawasia WF, Khan MS, Usman MS, et al. Safety and efficacy of transcatheter aortic valve replacement for native aortic valve regurgitation: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2019; 93: 345-53.\u003c/li\u003e\n\u003cli\u003eSannino A, Gargiulo G, Schiattarella GG, et al. Increased mortality after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and low ejection fraction: a meta-analysis of 6898 patients. Int J Cardiol 2014; 176: 32-9.\u003c/li\u003e\n\u003cli\u003eBaron SJ, Arnold SV, Herrmann HC, et al. Impact of ejection fraction and aortic valve gradient on outcomes of transcatheter aortic valve replacement. J Am Coll Cardiol 2016; 67: 23492358.\u003c/li\u003e\n\u003cli\u003eDrews T, Pasic M, Buz S, et al. Elective use of femoro-femoral cardiopulmonary bypass during transcatheter aortic valve implantation. Eur J Cardiothorac Surg 2015; 47: 24-30; discussion \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Aortic regurgitation, Transcatheter aortic valve replacement, Left ventricular ejection fraction, Extracorporeal membrane oxygenation, Heart failure","lastPublishedDoi":"10.21203/rs.3.rs-8976112/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8976112/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFor patients with pure aortic regurgitation (AR) with low left ventricular ejection fraction (LVEF), the net clinical benefit of current treatment options remains uncertain. Our goal was to evaluate the clinical outcomes of TAVR in such patients and the periprocedural clinical value of extracorporeal membrane oxygenation (ECMO).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this multicenter study, patients who underwent TAVR between June 2017 and May 2021 were enrolled. Patients were divided into three groups based on LVEF and whether they received preventive ECMO. The primary endpoint was 2-year all-cause mortality.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 751 patients were included, including 51 patients (6.8%) in the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group, 38 patients (5.1%) in the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group, and 662 patients (88.1%) in the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% group. The three groups with LVEF were 26.0 (24.0\u0026ndash;32.0)%, 33.0 (30.0\u0026ndash;34.0)%, and 52.0 (48.0\u0026ndash;57.0)%. The primary endpoint of patients with LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% was similar to that of patients with LVEF\u0026thinsp;\u0026gt;\u0026thinsp;35% (Hazard ratio: 1.18; 95% CI: 0.69\u0026ndash;2.03, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.547). The 2-year LVEF of patients with LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% was significantly increased. Notably, the ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group had a lower incidence of the primary endpoint than the non-ECMO\u0026thinsp;+\u0026thinsp;LVEF\u0026thinsp;\u0026lt;\u0026thinsp;35% group (hazard ratio: 0.47; 95% confidence interval: 0.17\u0026ndash;0.82, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.042).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe 2-year clinical outcomes among the three groups were similar, and LVEF was significantly improved. Timely implantation of ECMO had potential clinical value for these patients.\u003c/p\u003e","manuscriptTitle":"TAVR in Patients with Aortic Regurgitation with Low LVEF: Clinical Outcomes and the Value of ECMO","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 00:51:16","doi":"10.21203/rs.3.rs-8976112/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-10T13:57:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176201409516461670488240658071267256905","date":"2026-04-04T13:34:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-02T08:50:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-31T04:52:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-10T10:08:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-10T06:44:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2026-03-10T06:05:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4dfe8594-c680-4c88-8d1f-59fa527bf0a0","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T00:51:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 00:51:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8976112","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8976112","identity":"rs-8976112","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}