Predictors Of Postoperative Left Ventricular Dysfunction Research Articles

Relationship between fragmented QRS complex and early left ventricular dysfunction after mitral valve repair

BackgroundPreoperative left ventricular (LV) ejection fraction (PreLVEF) and preoperative LV end-systolic diameter (PreESD) are known predictors for postoperative LV dysfunction after mitral valve repair (MVR). Fragmented QRS (fQRS) evaluated in 12-derivation electrocardiography has widely been accepted as a sign of myocardial fibrosis.In the present study, we aimed to evaluate the relationship between fQRS in preoperative 12‑lead electrocardiography (ECG) and postoperative LV dysfunction that develop after MVR in patients with severe primary mitral regurgitation (MR) due to mitral valve prolapse (MVP). MethodsFrom 2019 to 2022, 49 patients who had undergone successful MVR surgery for severeMR caused by MVP were enrolled in the study. The preoperative and postoperative echocardiographic data were collected retrospectively. We analyzed the demographic, echocardiographic, operative and postoperative parameters to assess the relationship between fQRS and early postoperative LV dysfunction, defined as an LVEF<60%. ResultsPreLVEF of all patients were ≥ %65. A total of 22 patients had fQRS (44.9%) and postoperative LV dysfunction was found to be 36.7%. A significantly higher rate of fQRS was observed in the group with postoperative LV dysfunction compared to the group without (12 (66.7%) vs 10 (32.3%), p: 0.036). In multivariate analysis for fQRS, PreESD, preoperative pulmonary artery systolic pressure (PrePASP), preoperative atrial fibrillation (PreAF), and male gender, only fQRS was found to be a significant predictor of postoperative LV dysfunction (p: 0.003, OR: 4.28, 95% CI (1.15–15.96). ConclusionfQRS was found to be a predictor of postoperative LV dysfunction in the early period after MVR. fQRS may be a readily available and cost-effective test that can be used in clinical practice to predict postoperative LV dysfunction in patients undergoing MVR.

Determinants of post-operative left ventricular dysfunction in degenerative mitral regurgitation

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Saudi Arabian Cultural Bureau. Background Chronic degenerative mitral regurgitation leads to volume overload causing left ventricular (LV) enlargement and eventually LV impairment. Current guidelines determining thresholds for intervention are based on LV diameters and ejection fraction. There is sparse data examining the value of LV volumes and newer markers of LV performance on outcomes of surgery in mitral valve prolapse. Purpose Identify the best markers of LV impairment after mitral valve surgery. Methods Prospective, observational study of patients with mitral valve prolapse undergoing mitral valve surgery. Pre-operative LV diameters, volumes, ejection fraction (LVEF), global longitudinal strain (GLS) and myocardial work measured. Post-operative LV impairment defined as LVEF &amp;lt; 50% at 1 year post-surgery. Results Eighty-seven patients included. 13% developed post-operative LV impairment. Patients with post-operative LV dysfunction showed significantly larger indexed LV end-systolic diameters (LVESD), volumes (LVESV), lower LVEF and more abnormal GLS than patients without post-operative LV dysfunction. In multivariate analysis, indexed LVESV (Odds ratio 1.11 (95% CI 1.01 – 1.23), p = 0.039) and GLS (odds ratio 1.46 (95% CI 1 – 2.14), p = 0.054) were the only independent predictors of post-operative LV dysfunction. The optimal cut-off of 36.3 ml/m2 for indexed LVESV had a sensitivity of 82% and specificity of 78% for detection of post-operative LV impairment. Conclusion Post-operative LV impairment is common. Indexed LV volumes (36.3ml/m2) provided the best marker of post-operative LV impairment.

Prognostic value of forward flow indices in primary mitral regurgitation due to mitral valve prolapse.

Degenerative mitral regurgitation (DMR) due to mitral valve prolapse (MVP) is a common valve disease associated with significant morbidity and mortality. Timing for surgery is debated for asymptomatic patients without Class I indication, prompting the search for novel parameters of early left ventricular (LV) systolic dysfunction. To evaluate the prognostic impact of preoperative forward flow indices on the occurrence of post-operative LV systolic dysfunction. We retrospectively included all consecutive patients with severe DMR due to MVP who underwent mitral valve repair between 2014 and 2019. LVOTTVI, forward stroke volume index, and forward LVEF were assessed as potential risk factors for LVEF <50% at 6 months post-operatively. A total of 198 patients were included: 154 patients (78%) were asymptomatic, and 46 patients (23%) had hypertension. The mean preoperative LVEF was 69 ± 9%. 35 patients (18%) had LVEF ≤ 60%, and 61 patients (31%) had LVESD ≥40 mm. The mean post-operative LVEF was 59 ± 9%, and 21 patients (11%) had post-operative LVEF<50%. Based on multivariable analysis, LVOTTVI was the strongest independent predictor of post-operative LV dysfunction after adjustment for age, sex, symptoms, LVEF, LV end systolic diameter, atrial fibrillation and left atrial volume index (0.75 [0.62-0.91], p < 0.01). The best sensitivity (81%) and specificity (63%) was obtained with LVOTTVI ≤15 cm based on ROC curve analysis. LVOTTVI represents an independent marker of myocardial performance impairment in the presence of severe DMR. LVOTTVI could be an earlier marker than traditional echo parameters and aids in the optimization of the timing of surgery.

665 Longitudinal strain impairment in organic mitral regurgitation: look beyond the valve

Abstract Aims Global longitudinal strain (GLS) is a hallmark of cardiac damage in mitral regurgitation (MR). GLS &amp;gt; −18% in patients with severe organic MR (OMR) and normal LV ejection fraction (LVEF) is an independent predictor of postoperative LV dysfunction. While it is known that GLS is impaired in less than severe functional ischaemic MR (FMR), the value of GLS in less than severe OMR is not known. We aimed to determine prevalence and determinants of any GLS impairment in OMR, in comparison to FMR. Methods We retrospectively evaluated 51 consecutive patients (33 OMR and 18 FMR) with mild-to-moderate, moderate and moderate-to-severe MR (Table*). Overall, GLS was higher in OMR than FMR (17.9±4.5 vs. 10.3±5.3, P&amp;lt;0.001), with rate of impairment of 45% in OMR and 89% in FMR (P= 0.0024). Results However, no significant difference was found in GLS between mild-to-moderate, moderate and moderate-to-severe MR patients within OMR (17.7±4.7 vs. 16.9±3.9 vs. 22.4±3, respectively, P&amp;gt;0.05), as well as FMR (9.8±6.6 vs. 10.7±5.3 vs. 10.4±5.3, respectively, P&amp;gt;0.05) groups. GLS correlated directly with left ventricular (LV) ejection fraction (EF) in both OMR (r=0.69, P&amp;lt;0.001) and FMR (r=0.90, P&amp;lt;0.001), and inversely with LV mass indexed for body surface area (LVMi) in both OMR (r = −0.50, P=0.005) and FMR (r = −0.48, P=0.042). While correlation with LVEF was better for FMR than OMR (Z − 1.95, P=0.026), correlation with LVMi was similar for OMR and FMR groups (Z − 0.082, P&amp;gt;0.05). Conclusions In patients with OMR, GLS may be reduced, despite normal LVEF, in less than severe MR. Prevalence and degree of GLS impairment in OMR is less than in FMR. In OMR, as well as in FMR, GLS impairment is independent of entity of MR, but rather correlates with LVMi, maybe reflecting impact of myocardial fibrosis derived by increased LVMi on GLS.

Global longitudinal strain by speckle-tracking echocardiography and feature-tracking cardiac magnetic resonance predicting left and right ventricular performance after mitral regurgitation repair

Preoperative accurate assessment of biventricular systolic function is, essential for the decision of the operative timing in patients with MR. This study sought to compare the value of 2-dimensional (2D) left ventricular (LV) speckle tracking (STE) and feature tracking (FT) against cardiac magnetic resonance (CMR) LV ejection fraction (EF) on predicting postoperative LV dysfunction and in the other hand, evaluate the remodeling of the RV after mitral valve repair. A total of 85 patients with degenerative mitral regurgitation (57,51±9,96 of age, 21,2% women) underwent LV and RV function assessment using CMR and 2D echocardiography a few days before and 7,7 months after mitral valve repair. Pre- and postoperative indexed LV and RV end-diastolic (EDV), end-systolic volumes (ESV), ejection fraction (EF), Echocardiographic GLS, GCS, and CMR GLS, GCS, GRS were measured. Prior to surgery LV volumes were significantly larger, 2D LV and RV STE and FT lower than normal volunteers. After a median follow-up of 7,7 after mitral repair, not only left and right ventricular volume indexed: LV EDVi, ESVi; RV EDVi, atrial volume but also STE (LVGLS-GCS) and FT (LVGLS, GCS, GRS) were significantly decreased (all P < 0,0001) while RV EF significantly improved ( P :0,01). In univariate analysis, preoperative GLS echo, CS MRI, ESV, and preoperative LV EF were significantly correlated with postoperative LV dysfunction; GLS and LV ESV were independent clinical predictors of postoperative LV dysfunction. 2D LV GLS provides strong additionaL value to predict postoperative LV dysfunction in degenerative mitral regurgitation, with higher predictive value than CMR-LVEF, CMR-FT-LVGLS, or FAC. This supports the use of STE-LVGLS to find the best surgical timing in patients with severe MR to prevent LV dysfunction and allow RV recovery.

Predictors of Left Ventricular Dysfunction After Surgery for Degenerative Mitral Regurgitation

This study was performed to determine whether strain can supplement the ability of left ventricular (LV) ejection fraction (LVEF) to predict postoperative ventricular dysfunction in patients undergoing mitral valve surgery for degenerative mitral regurgitation (DMR). From 2004 to 2017, 520 patients with an LVEF of 60% or more underwent mitral valve surgery (98% repair) for DMR. All patients had preoperative, predischarge, and follow-up (mean, 5.0 ± 3.6 years) echocardiograms. Speckle tracking was performed in 119 of 520 patients (22.9%) to determine LV strain, right ventricular free-wall strain, and left atrial longitudinal strain. Multivariate logistic and Cox regression models were used in this subgroup to evaluate associations with early postoperative LV dysfunction and medium-term overall survival, respectively. Median preoperative LVEF of the entire cohort was 65%. Based on predischarge echocardiogram, 449 patients (86.3%) maintained postoperative LVEF of 50% or greater. Seventy-one patients (13.7%) had a predischarge LVEF of less than 50%, 49 (9.4%) had a predischarge LVEF of 40% to 49%, and 22 (4.2% overall) had a predischarge LVEF of less than 40%. Abnormal preoperative LV, right ventricular, and left atrial strain measurements were significantly associated with the development of postoperative LV dysfunction, but preoperative hemodynamic and non-strain echo parameters did not vary enough in absolute values to be clinically useful as predictors of postoperative LV dysfunction. Preoperative strain measurements in DMR patients were significantly associated with superior capabilities of detecting underlying LV dysfunction despite preserved preoperative LVEF. Strain analysis may serve as another marker for optimal timing of surgical intervention in DMR patients.

Left Ventricular Global Longitudinal Strain as a Marker of Left Ventricular Dysfunction after Mitral Valve Surgery in Organic Mitral Regurgitation

Introduction Due to lack of reliable echocardiographic parameters to predict recovery after the surgery, the optimal timing of mitral valve surgery in asymptomatic patients with mitral regurgitation (MR) remains controversial. Therefore this study sought to evaluate left ventricular (LV) global longitudinal strain (GLS), assessed with 2 dimension speckle-tracking echocardiographic analysis (2D- STE) as a predictor of LV dysfunction after mitral valve repair (MVR). Method We conducted a meta-analysis and searched MEDLINE, EMBASE, and Cochrane. Selected studies reported GLS and ejection fraction (EF) amongst asymptomatic patients with moderate to severe organic MR and preoperative preserve LVEF. In all studies echocardiography was performed at baseline and long-term follow-up (>6 months) after MVR. The two primary outcomes were the pooled standardized mean difference (SMD) of EF and GLS between patients with LV dysfunction at follow up which was defined as LVEF Result Four studies met the inclusion criteria. A total of 799 patients (65.9% men, mean age 61.3) with moderate to severe organic MR who underwent successful MVR were included. LV dysfunction at follow up was present in 57 (16.2%) patients. The mean preoperative LVEF and LVGLS were 63.8% (SD 6.4) and −20.7 (SD 3.2), respectively. Many relevant outcomes were inconsistently recorded across studies and thus only a select few were eligible for further analysis. Notably, patients with postoperative LVEF ≥ 50% had a more negative GLS at baseline (i.e. closer to normal) when compared to the group with post-operative LV dysfunction (GLS pooled SMD = 2.94; 95% CI: 1.87-4.02; I-squared 17%, tau-squared heterogeneity p = 0.15). Furthermore, using baseline GLS as a predictor of post-op LV dysfunction was associated with a sensitivity of 79% (95% CI: 0.75-0.83) and a specificity of 75% (95% CI: 46-96%). Conclusion In asymptomatic patients with moderate to severe organic MR and preoperative normal LVEF who underwent MVR, LVGLS demonstrated to be a predictor of postoperative LV dysfunction.

Indications for intervention in asymptomatic children with chronic mitral regurgitation.

Based on outcome data, surgery is recommended for asymptomatic adults with chronic mitral regurgitation (MR) and systolic dysfunction, marked left ventricular (LV) dilation, pulmonary hypertension, atrial fibrillation, or high likelihood of successful repair; but indications for children are poorly defined. We sought to determine predictors of postoperative LV dysfunction in asymptomatic children with chronic MR. The surgical database was searched for all children who underwent mitral valve surgery for chronic MR (2000-2012). Exclusion criteria were preoperative symptoms, acute MR, cardiomyopathy, or other defects affecting LV size. Preoperative and latest follow-up clinical and echocardiographic data were obtained. LV dysfunction was defined as ejection fraction (EF) ≤55% or shortening fraction (SF) ≤28%. Associations between preoperative factors and late LV dysfunction were determined using univariate Poisson regression. For the 25 children who met criteria, preoperative median LV end systolic Z score (LVESZ) was 5.3, EF was 65%, and SF was 34%. At follow-up (median 3.9 years), nine patients (36%) had LV dysfunction. Lower preoperative SF (OR 0.6, p < 0.001) and higher LVESZ (OR 1.7, p < 0.01) were associated with late LV dysfunction. LVESZ ≥ 5 combined with SF ≤ 33% had a sensitivity of 89%, specificity of 88%, and negative predictive value of 93% for late LV dysfunction. Only 1/14 patients with preoperative SF > 33% had late LV dysfunction. For asymptomatic children with chronic MR, surgery should be considered before LVESZ exceeds five and SF falls below 33%. Patients with SF > 33% may be followed with serial echocardiographic measurements.

Predicting early left ventricular dysfunction after mitral valve reconstruction: The effect of atrial fibrillation and pulmonary hypertension

The preoperative ejection fraction (EF) and left ventricular (LV) end-systolic dimension are known predictors of postoperative LV dysfunction after mitral valve repair. We investigated the effect of a preoperative history of atrial fibrillation and moderate pulmonary hypertension (defined as pulmonary artery systolic pressure >50 mm Hg) on early postoperative LV dysfunction. From 2003 to 2010, 632 patients who had undergone successful mitral valve repair surgery for degenerative disease were included in the present study. The preoperative and postoperative echocardiographic data and postoperative outcomes were collected retrospectively. We analyzed the demographic, hemodynamic, and echocardiographic parameters to assess the predictors of early postoperative LV dysfunction, defined as an LVEF <50%. The mean age of the cohort was 57 ± 13 years. All patients had less than mild mitral regurgitation onpostoperative echocardiography. After mitral valve repair, a significant decrease in the LVEF (60% ± 8% to 54% ± 9%), LV end-systolic diameter (36 ± 7 mm to 33 ± 7 mm), and LV end-diastolic dimension (56± 8 mm to 48 ± 7 mm) was observed at early postoperative echocardiography (P<.001). On multivariate regression analysis, preoperative atrial fibrillation, pulmonary hypertension, and LV end-systolic dimension were independent predictors of the postoperative LVEF (P=.035 and P<.001, respectively). Preoperative atrial fibrillation (odds ratio, 1.97; 95% confidence interval, 1.28-3.02; P=.002) and pulmonary artery systolic pressure >50 mm Hg (odds ratio, 1.82; 95% confidence interval, 1.11-2.97; P=.017) increased the risk of postoperative LV dysfunction by almost twofold. In addition to the established predictors of postoperative LV dysfunction, the presence of preoperative pulmonary hypertension and a history of atrial fibrillation in patients undergoing mitral valve repair surgery increased the risk of early postoperative LV dysfunction by almost twofold.

159: Preoperative atrial fibrillation predicts outcome after valve repair for mitral valve prolapse

The aim of this study is to assess the impact of preoperative AF on outcome in patients undergoing MVR for mitral valve prolapse (MVP). Between 1991 and 2009, 348 consecutive patients underwent MVR for MR due to MVP (follow-up: mean duration 105±50 months). Echocardiography was performed preoperatively and 9 to 12 months after surgery. Post operative left ventricular dysfunction (LVD) was defined as ejection fraction (EF) < 50%. There were 81 patients (23.3%) in AF at baseline. Preoperative EF decreased from 67.2±9.6% to 58.9±10.1% post operatively (p< 0.0001). Patients in AF were older (70±9 vs. 64±11 years, p<0.0001), more often in NYHA III – IV class (p=0.028), had a significantly higher EuroSCORE (4.4±5.7 vs. 2.8±2.4, p<0.0001). At baseline, patients in AF had a lower preoperative EF (64±11 vs. 68±9%, p=0.001). Early mortality was 4.9% in patients with preoperative AF vs. 1.9% in sinus rhythm (n=5, p=0.13). Multivariate analysis did not identify AF as a predictor of early mortality whereas EuroSCORE (p =0.001) and low pre-operative EF (p=0.001) were independent risk factors for early mortality. On multivariate analysis adjusted for EuroSCORE, NYHA III – IV class and preoperative LVEF, preoperative AF was identified as an independent predictors of overall mortality (OR 1.9; p=0.03) and of occurrence of heart failure (OR 2.2, p=0.054). After adjustment for gender, EuroSCORE, NYHA III-IV class and preoperative EF, preoperative AF and pre-operative EF were the 2 predictors of post-operative LVD (OR 2.2 p=0.025 and OR 1.04, p=0.03 respectively). Preoperative AF is an independent predictor of long term mortality and post-operative LVD after MVR for MPV.

Abstract 9728: The Timing of Valve Repair for Severe Degenerative Mitral Regurgitation and the Long-term Left Ventricular Function

Background: The current ACC/AHA guideline recommends early mitral valve (MV) repair for asymptomatic severe mitral regurgitation (MR) in the absence of left ventricular (LV) dysfunction. However, the effects of early MV repair on the long-term LV function and the threshold of the preoperative parameters to maintain favorable long-term LV function have not been clarified. This study aimed to evaluate the incidence and predictors of postoperative LV dysfunction as well as the clinical outcomes. Methods: A total of 908 patients who underwent MV repair for severe degenerative MR in our institution between 1996 and 2010 were retrospectively reviewed. Among them, both preoperative and 3-year postoperative echocardiographic data were available in 437 patients. Pre- and postoperative echocardiographic data and clinical outcomes were evaluated. Results: Receiver-operating characteristics curve analysis identified preoperative LV ejection fraction (EF) &gt;65% (area under curve (AUC), 0.65; P&lt;0.001) and LV end-systolic dimension (ESD) &lt;38 mm (AUC, 0.68; P&lt;0.001) as cut off values for predicting LVEF ≥60% 3 years after surgery. Patients were divided into 2 groups according to the preoperative LV measures; group A (n=193), LVEF &gt;65% and LVESD &lt;38mm and group B (n=280), LVEF ≤65% and/or LVESD ≥38mm. There were significantly higher rates of postoperative LV dysfunction in group B (A vs B, 24% vs 49%, P&lt;0.001). Moreover, the 10-year event-free survival rate, defined as a composite of death, hospitalization because of heart failure, and recurrent MR was significantly lower in group B than those in group A (A vs B, 86% vs 70%, P=0.02). Among patients in group A, preoperative LVESD was the only independent predictor of postoperative LV dysfunction. Conclusion: Simple preoperative echocardiography measures allow the prediction of postoperative LV dysfunction. Patients with preoperative LVEF &gt;65% and LVESD &lt;38 mm may offer better long-term postoperative LV function.

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

The best predictor for postoperative left ventricular (LV) systolic dysfunction in patients with chronic aortic regurgitation is still a matter of debate. The aim of this study was to assess the clinical significance of preoperative systolic radial strain rate (Ssr) derived from tissue Doppler echocardiography as a predictor of postoperative LV systolic dysfunction in patients with chronic aortic regurgitation. In 52 patients (mean age, 58 years; 13 women) with isolated chronic aortic regurgitation, we performed standard and tissue Doppler echocardiography before and after operation, obtained echocardiographic parameters such as LV dimensions and LV ejection fraction, and measured Ssr in 4 walls of the LV. Linear regression analysis determined correlations between preoperative parameters and postoperative LV ejection fraction. Receiver-operating characteristic curve analysis assessed the optimal cutoff values of parameters that predicted postoperative LV systolic dysfunction (ejection fraction <50%). The operation caused significant decreases in LV dimensions and volumes and significant increases in Ssr (1.94+/-0.64 to 2.39+/-0.83 per second; P<0.001) and ejection fraction (53.0+/-8.7 to 59.0+/-8.8%; P<0.001). Multiple regression analysis demonstrated that averaged Ssr was the only independent predictor of postoperative LV systolic dysfunction among the covariates examined (P<0.001). Using receiver-operating characteristic curve analysis, averaged Ssr yielded the greatest area under the curve among preoperative parameters (0.80) and was indicated to be a good predictor of postoperative LV dysfunction, with 90.9% sensitivity and 73.2% specificity (cutoff value, 1.82 per second). Measurement of preoperative averaged Ssr is useful in predicting postoperative LV systolic dysfunction and optimizing surgical timing in patients with isolated chronic aortic regurgitation.

Echocardiographic prediction ofleft ventricular dysfunction aftermitral valve repair for mitral regurgitation as anindicator to decide the optimal timing of repair

ObjectivesThis study sought to determine whether echocardiography before mitral valve repair (MVR) for mitral regurgitation (MR) was predictive of postoperative left ventricular (LV) dysfunction and useful for deciding the optimal timing of repair. BackgroundSome reports have shown that the preoperative echocardiographic data of left ventricular ejection fraction (LVEF) and left ventricular end-systolic diameter (LVDs) were good predictors of postoperative LV dysfunction. However, few reports were based on long-term follow-up data of large numbers of patients who underwent MVR in the last decade. MethodsA total of 274 patients with moderate or severe MR underwent MVR between October 1, 1991, and September 30, 2000. Among them, 171 patients who had both an operation for isolated MR due to degenerative pathology and a postoperative echocardiogram were studied. Postoperative echocardiograms were performed 3.9 ± 2.4 years after the operation. ResultsThe LVEF decreased from 66 ± 10% before surgery to 63 ± 11% after surgery (p < 0.0001). On univariate analysis, preoperative LVEF and LVDs correlated with postoperative LVEF (r = 0.41 and r = −0.39, respectively). Overall, postoperative LV dysfunction (defined as LVEF <50%) was not frequent (12%). However, the incidence of postoperative LV dysfunction was high in patients with preoperative LVEF <55% (38%) or LVDs ≥40 mm (23%). ConclusionsIn patients with MR, the echocardiographic data of LVEF and LVDs were good predictors of postoperative LV dysfunction. When a decrease in LVEF or an increase in LVDs is detected, MVR should be considered to preserve postoperative LV function.