with 201-Thallium at rest and exercise. A multicenter study: coronary angiographic and electrocardiographic correlations We read with interest the paper by Smith, McAnulty and Rahimtoola regarding aortic stenosis (AS) with heart failure.1 These authors observed improvement of impaired left ventricular performance after aortic valve replacement, but raise the possibility that myocardial dysfunction might become so far advanced in some patients that it might not improve after valve replacement. We have reported a similarly gratifying response in patients with AS.2 Since ventricular dysfunction was more advanced in our series than in Smith's, comparison of results helps to answer the question of irreversibility.Ours was a consecutive series of 12 patients receiving aortic valve replacement for AS, with or without minor aortic regurgitation. All had clinical and readiographic evidence of heart failure, and most had secondary renal, hepatic and/or cerebral dysfunction. The mean left ventricular end-diastolic volume index was 189 ml/m2 and the calculated ejection fraction (EF) ranged from approximately 0-0.20 (only two of Smith's 18 patients had EF < 0.30). The transaortic gradients were often small (range 16-70 mm Hg peak-topeak) despite small aortic valve areas, re-emphasizing Smith's point that measurement of cardiac output and calculation of valve area is often crucial to recognition of the correct diagnosis. Five patients with associated coronary artery disease (CAD) received aortocoronary grafts at the time of valve replacement. There were three early deaths attributable to continued left ventricular (LV) dysfunction, all among the CAD patients. An additional CAD patient died because of a strike early after operation. All eight survivors moved from class III-IV to class I-IT. Postoperative treadmill exercise tolerance was 50-105% of normal. In six patients, there was marked diminution of ventricular size and improvement of EF (postoperative mean = 0.45, range 0.34-0.75).We conclude that without CAD, even the most advanced LV dysfunction associated with AS can be expected to improve markedly with aortic valve replacement. When coronary disease accompanies LV dysfunction in AS, the mortality risk of surgery rises dramatically, presumably because there is more extensive scarring of the left ventricle than in "pure" AS. The long-term reversal of heart failure in one of our CAD patients, however, makes us reluctant to conclude that surgery should not be performed in this setting. Because of the hopeless prognosis of these patients without operation, perhaps even a small chance of success should be pursued.ROBERT
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