Influence of preoperative left ventricular function on results of homograft replacement of the aortic valve for aortic stenosis

Thompson, Richard H.; Yacoub, Magdi H.; Ahmed, Mohammed; Seabra-Gomes, R; Rickards, Anthony F.; Towers, M

doi:10.1016/0002-9149(79)90355-2

Cited by 51 publications

(9 citation statements)

References 27 publications

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“…Although in all published reports and in our cases left ventricular status improved markedly in most patients (reflected by the decrease in enddiastolic volume and the tendency of the shape of the cavity to return to normal), in some cases the ventricular status does not change after operation. The proportion of cases without change after surgery varies in different studies: 17% in our study, 33% in that of Herreman et all and 50% in that of Thompson et al19 In the present study, no correlation was found between the decrease in end-diastolic volume and the periods between operation and the first hemodynamic investigation, which varied from [6][7][8][9][10][11][12][13][14][15] months. The absence of any correlation with the preoperative end-diastolic volume suggests that even at an advanced stage of left ventricular dilatation (e.g., greater thad 250 ml/m2) (patients 6, 14 and 15), enddiastolic volume may still decrease after operation.…”

Section: Discussioncontrasting

confidence: 50%

Hemodynamic and angiographic evaluation of aortic regurgitation 8 and 27 months after aortic valve replacement.

Toussaint¹,

Cribier²,

Cazor³

et al. 1981

Circulation

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SUMMARY Eighteen patients with chronic aortic insufficiency were evaluated hemodynamically and angiographically 8 months after aortic valve replacement. Both the pulmonary artery diastolic pressure and the left ventricular end-diastolic volume decreased significantly (p < 0.001), but the mean ejection fraction and the cardiac output remained identically lowered, though some individual cases showed improvement. The relative reduction in end-diastolic volume correlated only with the preoperative ejection (p < 0.05) and regurgitation fractions (p < 0.02).In the 10 patients whose left ventricular volume remained high or ejection fraction low, a second evaluation was performed 27 months after surgery. The left ventricular end-diastolic volume was significantly lowered (from 151 to 120 mI/m2, p < 0.05) back to normal in five cases. The systolic and diastolic ventricular shape returned to normal. Cardiac index and ejection fraction were unchanged.These results show a marked improvement a few months after aortic valve replacement, with a further improvement several months later, as shown mainly by the decrease of left ventricular end-diastolic volume and the return to normal of left ventricular cavity shape. However, in most cases, the ejection fraction remained at its preoperative value, suggesting that surgery should be performed early, before myocardial deterioration appears.AORTIC REGURGITATION produces no clinical symptoms at first1' 2 because the left ventricle is initially the only cardiac chamber involved and can compensate for the regurgitation. During this time, the total cardiac volume increases slowly, pulmonary pressures remain normal, and left ventricular function shows no evidence of change. The alteration in left ventricular function is, however, a major factor in the postoperative prognosis.37The best time for valve replacement is difficult to determine, despite precise clinical, hemodynamic and angiographic data, because the relative risks involved in the consequences of prolonged aortic regurgitation, and those inherent in surgery and prosthetic valves, are not easy to determine.Evaluation of the results of valve replacement in relation to the pre-and postoperative hemodynamic and angiographic findings has only been undertaken in a few studies that, for the most part, involved few patients.8"-' The aim of the present study was to determine which preoperative factors have a prognostic value, to assess the reversibility of the left ventricular changes and to ascertain the optimal time for valve replacement. 18-65 years), suffering from an isolated, marked, long-standing aortic regurgitation. Its etiology was rheumatic in 10 cases, infective endocarditis in six and unknown in the other two. No patient had associated coronary disease and coronary arteriography, systematically performed in the 15 patients over 40 years old, was normal. Eleven patients were in functional class I or II of the New York Heart Association and seven were in class III or IV. Seventeen showed an increase in heart size on a standar...

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Section: Discussioncontrasting

confidence: 50%

Hemodynamic and angiographic evaluation of aortic regurgitation 8 and 27 months after aortic valve replacement.

Toussaint¹,

Cribier²,

Cazor³

et al. 1981

Circulation

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“…Previous studies have described improvement in ventricular function after valve replacement, both in patients with normal and reduced pre-operative ejection fractions (Croke et al, 1977;Kennedy et al, 1977;Smith et al, 1978;Thompson et al, 1979). The degree of improvement in ejection fraction has been found to be greater in patients with impairment of left ventricular function than in those with preserved function (Kennedy et al, 1977;Thompson et al, 1979).…”

Section: Discussionmentioning

confidence: 98%

Severe left ventricular dysfunction in critical aortic stenosis—reversal following aortic valve replacement

Dymond

Wolf

Schmidt

1983

Postgraduate Medical Journal

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SummaryA case of aortic valve stenosis is reported with progressive left ventricular dysfunction demonstrated by radionuclide angiography. A gradient of 120 mmHg was present across the aortic valve. At the time of surgery, the patient was in severe cardiac failure with a left ventricular ejection fraction of 22%.Two months postoperatively,the patient was asymptomatic, and repeat radionuclide anglography demonstrated an ejection fraction of 93%. The reversible nature of this patient's ventricular dysfunction suggests that the cardiac failure was related to 'afterload mismatch' caused by the stenotic valve, rather than due to depressed contractility. The encouraging result in this patient reinforces the view that surgical intervention is warranted in some patients with critical aortic stenosis and extreme impairment of left ventricular function, and that the close relation between ejection fraction and operative survival may not hold true in aortic stenosis.

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“…They include valve related thromboembolism, thrombotic occlusion of the valve, haemorrhagic complications for patients requiring anticoagulation, prosthetic valve dysfunction or paravalvar regurgitation requiring reoperation, and a higher risk of endocarditis than with a stenosed native valve. Sudden death unrelated to exercise continues to occur in these patients despite valve replacement.3 12 The considerable mortality and complications associated with aortic valve replacement should not be overlooked, especially in the case of an asymptomatic patient for whom prognostic benefit is the sole surgical indication.…”

Section: Julian C Vaile Michael J Griffithmentioning

confidence: 99%

“…This argument is based on two flawed assumptions. First, that myocardial deterioration associated with aortic stenosis is irreversible; in fact there is good evidence that ventricular dysfunction, even when advanced, is reversible after aortic valve replacement.3 12 Second, that most asymptomatic patients will quickly develop symptoms and thus require surgery; however, in the two largest series of initially asymptomatic patients with significant aortic stenosis, only 10% (after 17 months' follow up) and 18% (after 20 months' follow up) actually required surgery.89…”

mentioning

confidence: 99%

Management of asymptomatic aortic stenosis: masterly inactivity but cat-like observation.

Vaile¹,

Griffith²

1997

Heart

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Influence of preoperative left ventricular function on results of homograft replacement of the aortic valve for aortic stenosis

Cited by 51 publications

References 27 publications

Hemodynamic and angiographic evaluation of aortic regurgitation 8 and 27 months after aortic valve replacement.

Hemodynamic and angiographic evaluation of aortic regurgitation 8 and 27 months after aortic valve replacement.

Severe left ventricular dysfunction in critical aortic stenosis—reversal following aortic valve replacement

Management of asymptomatic aortic stenosis: masterly inactivity but cat-like observation.

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