Chronic aortic regurgitation: reassessment of the prognostic value of preoperative left ventricular end-systolic dimension and fractional shortening.

Abstract

The prognostic significance of a preoperative echocardiographic left ventricular endsystolic dimension (ESD) greater than 55 mm and/or fractional shortening (FS) of 25% or less was evaluated retrospectively in 84 patients who had undergone aortic valve replacement for isolated chronic aortic regurgitation due to various causes. Postoperative survival, improvement in symptoms, and echocardiographic evidence of regression of left ventricular dilatation and hypertrophy were compared between patients with a preoperative ESD greater than 55 mm (category 1) and those with an ESD of 55 mm or less (category 2) and between patients with FS of 25% or less (category 3) and those with FS greater than 25% (category 4). Patients in categories 1 and 3 had a higher preoperative left ventricular end-diastolic dimension (EDD) and cross-sectional area than those in categories 2 and 4, respectively, but their preoperative functional impairment (NYHA class) was similar. There were 13 deaths, only two of which (one early, one late) could be attributed to left ventricular dysfunction. In both, FS was 25% or less and in one ESD was greater than 55 mm. There was a weak association without useful positive predictive value between the echocardiographic variables and postoperative death due to all causes. Among 42 patients with a preoperative ESD greater than 55 mm and/or FS of 25% or less, 33 (79%) were alive at a mean follow-up of 29.5 months. Symptoms improved in all categories of survivors, with the postoperative NYHA class being similar between categories 1 and 2 and between categories 3 and 4. Among 48 survivors with high-quality echocardiograms both before and after surgery, EDD fell in all groups but fell to a lesser extent in category 3 than in category 4. Postoperative cross-sectional area fell to the same level in all categories. Follow-up intervals were similar in all categories. We conclude that in patients undergoing aortic valve replacement for chronic aortic regurgitation, a preoperative ESD greater than 55 mm or an FS of 25% or less does not reliably predict early or late death, does not correlate with lack of improvement in symptoms, and does not preclude postoperative regression of left ventricular dilatation and hypertrophy. Thus these echocardiographic criteria alone cannot be used for the timing of surgical intervention in these patients. Circulation 71, No. 4, 669-680, 1985

Quantitative Echocardiographic Determinants of Clinical Outcome in Asymptomatic Patients With Aortic Regurgitation

“…Despite "preserved" EF, higher ESVI (Ն45 ml/m 2 ) independently predicts more cardiac events within each AR grade. This result reconciles previous discordant data (3,7,16,17,29,31,32) and, by normalizing to body size, is equally applicable to men and women, avoiding gender-bias from non-normalized LV dimensions (14). Thus, quantitative echocardiography provides comprehensive determinants of outcome and is essential for clinical management of asymptomatic AR.…”

Indications for heart valve replacement

“…determined that an echocardiographically measured end-systolic diameter >55 mm and a left ventricular fractional shortening <25% were potent predictors of operative mortality or postoperative congestive heart failure. Of 13 patients with both these characteristics, 9 died within three years of sur- 27 comborated these findings in a retrospective study of 84 patients undergoing aortic valve replacement for isolated chronic aortic insufficiency. The operative mortality and postoperative clinical improvement appeared independent of preoperative end-systolic diameter ( > 55 mm) and preoperative fractional shortening ( c 25 %).…”

Regression of left ventricular hypertrophy in ?Previously untreated? hypertensive blacks after 6 months of blood pressure reduction with alpha- and beta-adrenergic blockade and thiazide therapy

“…In general, when left ventricular load is reduced by means of aortic valve replacement, in patients with aortic stenosis or insufficiency a regression in LV mass is associated with an improved prognosis, increased lifespan, and decreased symptomatology [32,33]. Thus it is reasonable to hypothesize that an analogous reduction in afterload by effective antihypertensive therapy would be associated with a parallel decrease in LV mass, and that such a result should be associated with an improved prognosis.…”