Abnormal left ventricular intracavitary flow acceleration in patients undergoing aortic valve replacement for aortic stenosis. A marker for high postoperative morbidity and mortality.

Abstract

Background. We examined the clinical and echocardiographic characteristics of patients undergoing aortic valve replacement for aortic stenosis whose continuous wave Doppler studies showed abnormal intracavitary flow acceleration.Methods and Resuls. The clinical and Doppler echocardiographic records of 53 consecutive patients undergoing aortic valve replacement for aortic stenosis were reviewed. Doppler echocardiography was performed at a mean of 6.6 days (range, 0-22 days) after surgery. Thirteen patients (group 1) had a dagger-shaped high-velocity systolic flow signal indicative of abnormal intracavitary flow acceleration on their postoperative Doppler study; group 2 comprised 40 aortic stenosis patients who underwent aortic valve replacement but had no postoperative evidence of abnormal intracavitary flow acceleration. Group 1 postoperative abnormal intracavitary flow velocities ranged from 1.8 to 6.8 m/sec (mean, 4.9±0.9 m/sec): Resulting dynamic gradients ranged from 10 to 184 mm Hg (mean, 104.6±32 mm Hg). Compared with group 2, group 1 patients had a distinctive ventricular geometry with more-pronounced hypertrophy, smaller cavities, and higher ejection fraction. Systolic anterior motion of the mitral valve did not accompany abnormal intracavitary flow acceleration in any patient. Six of 13 group 1 patients suflered postoperative hemodynamic compromise characterized by severe hypotension despite adequate pulmonary capillary wedge pressures; group 1 postoperative mortality was significantly greater than that seen in group 2 patients (38% versus 12%, p<0.05).Conclsions. Abnormal intracavitary flow acceleration after aortic valve replacement for severe aortic stenosis is associated with a distinctive ventricular geometry and supernormal systolic function but not systolic anterior motion of the mitral valve. Such flow acceleration appears to be a marker for increased postoperative morbidity and mortality. Preoperative and postoperative Doppler echocardiography may be useful in risk stratification and guiding therapy. (Circulation 1992;86:926-936)

2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

“…78 -80 Another problem that is particularly common in elderly patients, especially women, is an excessive or inappropriate degree of hypertrophy; wall thickness is greater than necessary to counterbalance the high intracavitary pressures. [81][82][83][84] As a result, systolic wall stress is low and ejection fraction is high; such inappropriate LV hypertrophy has been associated with high perioperative morbidity and mortality. 81,83 …”

“…Likewise, excessive or inappropriate hypertrophy associated with valvular stenosis can be a marker for perioperative morbidity and mortality. 81,83 Preoperative recognition of elderly patients with marked LV hypertrophy followed by appropriate perioperative management can reduce this morbidity and mortality substantially. There is no perfect method for weighing all of the relevant factors and identifying specifically high-and low-risk elderly patients, but this risk can be estimated well in individual patients.…”

Delayed-Onset Systolic Anterior Motion of the Mitral Valve After Aortic Valve Replacement for Severe Aortic Stenosis

“…[1][2][3] Although SAM with an associated LVOT gradient sometimes occurs after AVR for AS, it is rarely related to clinical symptoms. Several reports have demonstrated that LVOT obstruction, with MR resulting from SAM after AVR, leads to hemodynamic collapse.…”

“…[1][2][3] However, such patients rarely present with clinical symptoms. Therefore, therapy for the reduction of left ventricular pressure gradient associated with SAM has not been established.…”

Left Ventricular Hypertrophy in Asymptomatic Nonsevere Aortic Stenosis

“…This view, accepted for the past 40 years 3 and perhaps counterintuitively expected to mitigate the effects of LV pressure overload on cardiovascular morbidity and mortality, has begun to be challenged by new clinical data, suggesting that moderate or severe LVH may be associated with adverse outcomes in AS 4,5 and that inappropriately increased LV mass, found in 17% of patients with mild to moderate AS 6 and in 67% of patients with asymptomatic severe AS, was associated with a 4.5-fold increased risk of cardiovascular events. 7 Conversely, the absence of hypertrophy in one third of the patients with severe AS seems to have no adverse effects on systolic function or survival.…”