Diastolic versus Systolic Left Ventricular Dysfunction as Independent Predictors for Unfavorable Postoperative Evolution in Patients with Aortic Regurgitation Undergoing Aortic Valve Replacement

Abstract

Background and Objectives: Chronic severe aortic valve disease is associated with important changes in left ventricle (LV) performance associated with eccentric or concentric LV hypertrophy. We aimed to assess the immediate prognostic implications of the type of the LV diastolic filling pattern (LVDFP) compared with LV systolic performance in patients with severe aortic regurgitation (AR) undergoing aortic valve replacement (AVR) and to define the independent echographic predictors for the immediate and long-term prognoses. Materials and Methods: We performed a prospective study enrolling 332 AR patients undergoing AVR, divided into two groups: Group A—201 pts with normal LV systolic function, divided into two subgroups (A1: 129 pts with a nonrestrictive LVDFP and A2: 72 pts with restrictive LVDFP), and Group B—131 pts with LV systolic dysfunction (LV ejection fraction LVEF < 50%), divided into two subgroups (B1: 83 pts with a nonrestrictive LVDFP and B2: 48 pts with restrictive LVDFP). Results: The early postoperative mortality rate was higher in patients with a restrictive LVDFP (11.12% in A2 and 12.5% in B2) compared with normal LV filling (2.32% in A1 and 7.63% in B1, p < 0.0001), regardless of the LVEF. The restrictive LVDFP—defined by at least one of the following echographic parameters: an E/A > 2 with an E wave deceleration time (EDt) < 100 ms; an isovolumetric relaxation time (IVRT) < 60 ms; or an S/D ratio < 1 in the pulmonary vein flow—was an independent predictor for early postoperative mortality, increasing the relative risk by 8.2-fold. Other independent factors associated with early poor prognosis were an LV end-systolic diameter (LVESD) > 58 mm, an age > 75 years, and the presence of comorbidities (chronic obstructive pulmonary disease-COPD or diabetes mellitus). On a medium-term, an unfavorable evolution was associated with: an age > 75 years (RR = 8.1), an LV end-systolic volume (LVESV) > 95 cm3 (RR = 6.7), a restrictive LVDFP (RR = 9.8, p < 0.0002), and pulmonary hypertension (RR = 8.2). Conclusions: The presence of a restrictive LVDFP in patients with AR undergoing AVR is associated with both increased early and medium-term mortality rates. The LV diastolic function is a more reliable parameter for prognosis than LV systolic performance (RR 9.2 versus 2.1). Other independent predictors for increased early postoperative mortality rate were: an age > 75 years, an LVESD > 58 mm, and comorbidities (diabetes mellitus, COPD), and for unfavorable evolution at 2 years postoperatively: an age > 75 years, an LVESV > 95 cm3, and severe pulmonary hypertension.

Incidence and Risk Factors for Long-Term Persistence of Diastolic Dysfunction after Aortic Valve Replacement for Aortic Stenosis Compared with Aortic Regurgitation

“…As in our study, other researchers have shown that the early postoperative evolution of patients with AR is usually more unfavorable [ 7 , 8 ]. Moreover, at 1 year postoperatively, the NYHA class and self-reported quality of life in our study groups was found better after the AVR for AS compared to AR, as was reported in other previous studies [ 22 ].…”

“…Most studies have shown that, in the majority of patients with AS, LV diastolic function returned to normal after the valve replacement [ 24 , 25 , 26 ]. In contrast, in AR, diastolic dysfunction with abnormal filling is maintained in a significant percentage of patients after surgical correction, being normalized late after surgery [ 27 , 28 , 29 ].…”

“…However, the presence of a restrictive diastolic pattern determined a more unfavorable postoperative evolution both in patients with AS and in patients with AR. Severe diastolic dysfunction was identified by regression analysis as an independent risk factor for death and hospitalization for heart failure, as other studies have shown [ 1 , 5 , 10 , 28 ] [ 30 , 31 ]. Therefore, we also sought to assess whether preoperative restrictive diastolic filling precluded postoperative LV remodeling and improved function, and thus might prove useful in identifying patients who benefit less from AVR.…”

“…Moreover, knowledge is still limited regarding immediate and long-term postoperative outcome in patients with restrictive LVDFP [ 26 , 27 , 28 ]. That is why another important question we tried to answer in our study was: does the reversibility of the restrictive flow pattern after AVR depend on the type of the aortic lesion?…”

“…The presence of a severely impaired diastolic function with a restrictive left ventricular (LV) diastolic filling pattern (LVDFP) determines a more unfavorable prognosis in any cardiac disease [ 1 , 2 , 3 ]. Although there are many studies on diastolic dysfunction, there is little information on diastolic dysfunction in the postoperative cardiac surgical patient undergoing valve replacement [ 4 , 5 , 6 ]. There are only a few studies that have evaluated the influence of the restrictive LVDFP on the postoperative course, but these are mostly heterogeneous, with relatively small populations and variable patient selection, being difficult to compare between them to draw a unified conclusion [ 1 , 2 , 3 , 7 , 8 , 9 ].…”