Echocardiography in chronic aortic insufficiency. Is valve replacement too late when left ventricular end-systolic dimension reaches 55 mm?

Abstract

SUMMARY To determine whether a ventricular (LV) end-systolic dimension (ESD) > 55 mm and LV left fractional shortening < 25% are risk factors for aortic valve replacement (AVR) in patients with aortic insufficiency, we analyzed the clinical course and M-mode echocardiograms in 47 consecutive patients who underwent AVR for isolated symptomatic Al. Group 1 patients (n = 27) had a preoperative ESD < 55 mm (mean 44 mm, range 30-52 mm) and group 2 patients (n = 20) had a preoperative ESD > 55 mm (mean 62 mm, range 55-85 mm). One patient in group 1 and 10 patients in group 2 had left ventricular fractional shortening < 25%. There were no perioperative or postoperative deaths during an average follow-up of 41 months (range 6-76 months). Five patients had perioperative myocardial infarctions (MIs), three in group 1 and two in group 2. Since myocardial protection with cold potassium cardioplegia was instituted, no patient has suffered a perioperative MI. The average preoperative New York Heart Association functional classification was 2.3 (group 1) and 2.6 (group 2). Postoperatively, it was 1.2 in group 1 and 1.1 in group 2. Thirty-three patients (20 in group 1 and 13 in group 2) had echocardiograms at least 1 year after AVR. Of these, LV-end diastolic dimension decreased from 67 + 6 to 53 + 6 mm (mean ± SD) in group 1 (p < 0.001) and from 79 3 to 55 ± 6 mm in group 2 (p < 0.001). The LVESD also decreased, but this is difficult to interpret because offrequent postoperative abnormal interventricular septal motion. The LV cross-sectional area, an index of LV mass, decreased in group 1 from 25 ± 5 to 20 ± 5 cm2 (p < 0.001) and in group 2 from 32 ± 9 to 20 + 5 cm2 (p < 0.001). Postoperative end-diastolic dimension and cross-sectional area were not significantly different between the two groups. We concluded that in aortic insufficiency, a preoperative ESD 2, 55 mm does not preclude successful AVR, as judged by long-term survival, symptomatic relief, and normalization of LV dimensions assessed by echocardiography.THE OPTIMAL management of patients with severe aortic insufficiency (Al) is still a matter of debate, especially in asymptomatic or minimally symptomatic patients.' The recommendation for aortic valve replacement (AVR) in these patients depends, among other factors,4 on the identification of the degree of left ventricular (LV) dysfunction beyond which the risks of perioperative and postoperative mortality and morbidity are increased.5Henry et al.6 used M-mode echocardiography to identify a population at high risk for AVR due to Al. In their experience, when the LV end-systolic dimension (ESD) was 55 mm or greater, AVR carried a higher risk of perioperative complications and postoperative death for congestive heart failure. Most of these patients had LV Forty-seven of the 70 patients met the criteria and were included in the study. All but one patient underwent preoperative right-and left-heart catheterization, including LV and aortic root cineangiography. In nine patients, angiographic quantification of LV volumes ...

Outcomes After Aortic Valve Replacement in Patients With Severe Aortic Regurgitation and Markedly Reduced Left Ventricular Function

“…For late morbidity after AVR, earlier studies have provided either no 4,7,15 or limited information. 8,16 Even in studies with data on morbidity, specific information is not available about patients with markedly reduced EF. 8,16 In our study, long-term morbidity after AVR is dissociated in the subgroup with LoEF, increased for heart failure, but similar for thromboembolism.…”

“…8,16 Even in studies with data on morbidity, specific information is not available about patients with markedly reduced EF. 8,16 In our study, long-term morbidity after AVR is dissociated in the subgroup with LoEF, increased for heart failure, but similar for thromboembolism. Therefore, our study establishes for the first time that patients with markedly reduced EF and severe AR represent a high-risk group even after successful AVR.…”

Fibrose miocárdica e remodelamento ventricular na insuficiência aórtica crônica importante

“…Over the two last decades 5,6 , clinical trials were based primarily on LV dimensions and systolic function as indications of the ideal timing for aortic valve replacement. This procedure interrupts the natural history of AR, but it exposes the patient to the risks of surgery and valve prosthesis implantation.…”

Contractile Reserve Determined on Exercise Echocardiography in Patients With Severe Aortic Regurgitation

“…1,4,23 Some surgical studies, however, have suggested that this parameter is too restrictive, based on the postoperative course of symptomatic and asymptomatic patients. 20, 24 Also, compared with exercise parameters, these parameters are relatively insensitive. 19,24 Therefore, although baseline LVESD is used to guide the timing of AVR, baseline LVESD cannot fully detect delayed LV dysfunction and postoperative LV dysfunction in severe AR.…”