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

Abstract

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...

Time course of regression of left ventricular hypertrophy after aortic valve replacement.

“…Whether this constitutes an evolution to normalcy or is evidence of subtle left ventricular dysfunction is unclear. In patients with aortic insufficiency, with the residual "excess" of hypertrophy over volume through the seeming differential rates of regression of the two, at the intermediate postoperative study left ventricular geometry was more ellipsoidal than preoperatively, as previously observed by Toussaint et al 5 This likely reflects the substantial improvement in end-diastolic wall stress that followed corrective surgery and likely occurred because longitudinal stresses tend to be relatively higher than circumferential and radial stresses, allowing greater resolution of the dimensional changes in those directions. This persisted through to the late study, although it was less pronounced with further regression of myocardial mass.…”

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

“…[235][236][237][238][239][240][241][242][243][244][245][246] With time, during which the ventricle develops progressive chamber enlargement and a more spherical geometry, depressed myocardial contractility predominates over excessive loading as the cause of progressive systolic dysfunction. This can progress to the extent that the full benefit of surgical correction of the regurgitant lesion, in terms of recovery of LV function and improved survival, can no longer be achieved.…”

Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: impact of preoperative left ventricular function.

“…During the course of the current study, our strategy for patient management in aortic regurgitation was changed because of data implicating left ventricular function and severity of symptoms as important determinants of postoperative prognosis. '-8, 13,17,20,[30][31][32][33][34][35] Hence, many patients with left ventricular dysfunction in the current study underwent operation before the development of severe symptoms or impaired exercise capacity. Fifty-four of the 80 patients (68%) were able to complete stage I of our treadmill protocol, including 33 of 50 (67%) with subnormal ejection fractions.…”