Importance of preoperative hypertrophy, wall stress and end-systolic dimension as echocardiographic predictors of normalization of left ventricular dilatation after valve replacement in chronic aortic insufficiency

Kumpuris, Andrew G.; Quiñones, Miguel Á.; Waggoner, Alan D.; Kanon, Donna; Nelson, Jean G.; Miller, Richard R.

doi:10.1016/0002-9149(82)90032-7

Cited by 110 publications

(23 citation statements)

References 25 publications

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“…Nonetheless, these studies do support inclusion of a more precise assessment of LV function in determining the prognosis of patients with chronic severe AR. Previous studies further suggest that contractile function is superior as a predictor of irreversible post-AVR myocardial dysfunction than preoperative LV dimensions or LVEF [15], supporting the likelihood of its utility for clinical outcome prediction. However, contractility has not been previously studied for prediction of survival after AVR for severe AR.…”

Section: Discussionmentioning

confidence: 86%

“…However, when symptoms are absent and LVEF is normal at rest, earlier work by us [1] and others [12] suggests that development of clinically evident HF [13], subnormal LVEF at rest or sudden death in the absence of AVR are best predicted by intrinsic myocardial contractility [1,12], which can be measured noninvasively [1]. Though suggested by small studies usually admixing several different valve lesions [14][15][16][17], the post-AVR prognostic utility of preoperative contractility is less well defined. Therefore, among an established cohort of patients with AR who underwent AVR, we aimed to relate postoperative survival to preoperative contractility and to compare the predictive value of this measure with previously established risk predictors [1,8,18,19].…”

Section: Introductionmentioning

confidence: 99%

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Survival after Aortic Valve Replacement for Aortic Regurgitation: Prediction from Preoperative Contractility Measurement

et al. 2018

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Background: Noninvasive measurement of myocardial contractility (end-systolic wall stress-adjusted change in left ventricular ejection fraction from rest to exercise [ΔLVEF – ΔESS]) predicts heart failure, subnormal LVEF_rest, and sudden death in asymptomatic patients with chronic severe aortic regurgitation (AR). Here we assess the relation of preoperative ΔLVEF – ΔESS to survival after aortic valve replacement (AVR). Methods: Patients who underwent AVR for chronic, isolated, pure severe AR (n = 66) were followed for 13.0 ± 6.4 event-free years. Preoperative ΔLVEF – ΔESS (from combined echocardiographic and radionuclide cineangiographic data) enabled cohort stratification into 3 terciles (–1 to –11% [normal or mild] contractility deficit, –12 to –16% [moderate], and ≤–17% [severe], identical with segregation in our earlier study) to relate preoperative contractility to postoperative survival and to age- and gender-matched US census data. Results: Since AVR, 22 patients died (average annual risk [AAR] for all-cause mortality for the entire co hort = 3.15%). Preoperative ΔLVEF – ΔESS predicted postoperative survival (p = 0.009, log rank test). By contractility terciles, all-cause AARs were 1.44, 2.58, and 6.40%. Survival was lower than among US census comparators (p < 0.02), but the “mild” tercile was indistinguishable from census data (p = ns). By multivariable Cox regression, survival prediction by pre-AVR ΔLVEF – ΔESS was independent of, and superior to, prediction by age at surgery, gender, preoperative functional class, LVEF_rest, LVEF_exercise, change in LVEF_{rest to exercise}, and LV diastolic or systolic dimensions (p ≤ 0.01, pre-AVR ΔLVEF – ΔESS vs. other covariates). Conclusion: In severe AR, preoperative contractility predicts post-AVR survival and may be prognostically superior to clinical, geometric and performance descriptors, potentially impacting on patient selection for surgery.

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Section: Discussionmentioning

confidence: 86%

Section: Introductionmentioning

confidence: 99%

Survival after Aortic Valve Replacement for Aortic Regurgitation: Prediction from Preoperative Contractility Measurement

et al. 2018

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“…11,24,25 LVESVI, which was also decreased with hydralazine (by 28% at 2 years), is an even more powerful predictor of future deterioration in left ventricular performance. [24][25][26][27][28] This may be related to the fact that this variable is an important determinant of left ventricular wall stress,3' a factor that strongly influences left ventricular function in patients with aortic valve disease.28,29A40-42 Whether vasodilator-induced changes in these measurements influence the outcome of patients with chronic aortic insufficiency still must be determined in future studies. Although the need for surgery was not a primary end point because of the limited sample size, it is noteworthy that the number of patients who either required surgery or displayed clinically worrisome reductions in resting EF that might herald the need for valve replacement was substantially greater in the placebo than in the drug group (e.g., 6:35 vs. 1:45).…”

Section: Discussionmentioning

confidence: 99%

Long-term vasodilator therapy of chronic aortic insufficiency. A randomized double-blinded, placebo-controlled clinical trial.

et al. 1988

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Although vasodilator drugs acutely reduce regurgitation and improve cardiac performance in aortic insufficiency, their long-term effects on left ventricular size and function are uncertain. Consequently, we performed a double-blinded, placebo-controlled trial using hydralazine in 80 minimally symptomatic patients who had clinically stable, moderate-to-severe aortic insufficiency. Patients randomized to hydralazine displayed a progressive reduction in left ventricular end-diastolic volume index (LVEDVI) measured by radionuclide angiography, the predetermined end point of the study. At 24 months, mean LVEDVI had been reduced by 30 38 ml/m2, an 18% reduction from baseline. In contrast, LVEDVI changed minimally in patients randomized to placebo, and the intergroup differences over time were statistically significant (p<0.03). The hydralazine group also experienced reductions in left ventricular end-systolic volume index and increases in ejection fraction that were significantly different (both p<0.01) from changes in placebo-treated patients. These findings show that long-term treatment with hydralazine reduces the volume overload in aortic insufficiency and suggest that such therapy may have a beneficial effect on the natural history of the disease. (Circulation 1988;78:92-103) P revious studies have shown that vasodilator drugs acutely reduce the regurgitant volume and improve cardiac performance in aortic insufficiency. 1-7 Consequently, vasodilator therapy has emerged as an important modality for the shortterm management of patients with this lesion. These findings also raise the possibility that long-term therapy may chronically reduce the volume overload to the left ventricle. maintain cardiac performance in or close to the normal range." However, prolonged volume overload often leads to deterioration in left ventricular performance so that later in the course, signs and symptoms of cardiac dysfunction frequently develop.8,'0 An intriguing prospect is that the prophylactic administration of a vasodilator drug during the stable plateau phase of volume overload might be able to reduce either the extent of left ventricular dilation or its progression. The present study was undertaken to test the hypothesis that long-term vasodilator therapy with oral hydralazine reduces the volume overload and, hence, the left ventricular end-diastolic volume in clinically stable, moderate-to-severe aortic insufficiency. It was conducted as a prospective, randomized, placebocontrolled, double-blinded trial with change in left ventricular volume measured by radionuclide angiography as the predetermined end point.

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“…[31][32][33] These conventional parameters have advantages of comprehensibility and manageability; however, they express dimensions and volumes of the LV or the change of these. Therefore, they are poor at detecting subtle myocardial damage, in that they cannot express LV myocardial behavior.…”

Section: Preoperative Predictor In Chronic Armentioning

confidence: 99%

Preoperative Systolic Strain Rate Predicts Postoperative Left Ventricular Dysfunction in Patients With Chronic Aortic Regurgitation

Onishi

Kawai

Tatsumi

et al. 2010

Circ: Cardiovascular Imaging

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Importance of preoperative hypertrophy, wall stress and end-systolic dimension as echocardiographic predictors of normalization of left ventricular dilatation after valve replacement in chronic aortic insufficiency

Cited by 110 publications

References 25 publications

Survival after Aortic Valve Replacement for Aortic Regurgitation: Prediction from Preoperative Contractility Measurement

Survival after Aortic Valve Replacement for Aortic Regurgitation: Prediction from Preoperative Contractility Measurement

Long-term vasodilator therapy of chronic aortic insufficiency. A randomized double-blinded, placebo-controlled clinical trial.

Preoperative Systolic Strain Rate Predicts Postoperative Left Ventricular Dysfunction in Patients With Chronic Aortic Regurgitation

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