Failure of balloon aortic valvuloplasty to result in sustained clinical improvement in patients with depressed left ventricular function

Abstract

Although balloon aortic valvuloplasty usually results in acute hemodynamic improvement, recurrent symptoms often occur within several months. The current study was designed to determine whether clinical characteristics, including invasive hemodynamic parameters of left ventricular (LV) performance, are predictive of short-term patient outcome. Eighty-one consecutive patients were prospectivety enrolled in the study protocol. High-fidelity dual sensor micromanometer catheters, digital ventriculography and aortography and Fick cardiac output were measured before and immediately after balloon aortic valvuloplasty. Stroke work was defined from pressure-volume loops. The acute hemodynamic results obtained in patients with overall improved symptoms were compared to those with recurrent symptoms at 3 months. Fifty-three patients (65%) were improved at 3-month evaluation (group 1), whereas 28 patients (35%) had either returned to symptoms at baseline (17), had undergone aortic valve replacement (3) or had cardiac death (8). Compared to patients with improved symptoms, patients with recurrent symptoms demonstrated a tower cardiac output, higher LV end-systolic volume, decreased LV ejection fraction, diminished LV stroke work and decreased LV peak positive dP/dt. The final aortic valve area and change in aortic valve area did not predict which patients would develop recurrent symptoms. Stepwise logistic regression revealed that LV ejection fraction was the only independent predictor of overall status at 3 months (p = 0.002). Eighty-four percent of patients with an ejection fraction >;45% were improved. In the group with an ejection fraction ≤45%, less than half of the patients demonstrated improved symptoms at short-term followup. Parameters of LV performance can accurately predict short-term patient outcome after balloon aortic valvuloplasty. Because patients with depressed baseline LV function are much less likely to have improved symptoms compared to patients with preserved LV performance, the clinical outcome of balloon aortic valvuloplasty appears primarily related to underlying LV function rather than any measurable change during the procedure.