Valve Replacement For Aortic Regurgitation Research Articles

Effect of Preoperative Left Ventricular Mass on Outcomes After Aortic Valve Replacement for Aortic Regurgitation.

We determined the left ventricular mass index (LVMI) cut-off value for the risk of major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing aortic valve replacement (AVR) for aortic regurgitation (AR) and investigated the effect of preoperative left ventricular remodeling on long-term outcomes postoperatively. Of the 1,580 patients who underwent surgical AVR at Shiga University of Medical Science between January 2002 and December 2022, we retrospectively analyzed data for 263 patients who underwent surgery for AR. The receiver operating characteristic curve showed that the cut-off value of preoperative LVMI for the incidence of MACCE was 200 g/m2(area under the curve=0.692). We compared postoperative outcomes between patients with preoperative LVMI >200 g/m2(n=92) and those with preoperative LVMI ≤200 g/m2(n=171) after adjusting for preoperative characteristics using inverse probability of treatment weighting. The mean (±SD) follow-up period was 6.9±5.1 years. The rate of MACCE at 10 years was significantly higher in patients with preoperative LVMI >200 g/m2than in those with preoperative LVMI ≤200 g/m2(25.6% vs. 13.5%; P=0.020). In multivariable Cox models, preoperative LVMI >200 g/m2was significantly associated with a higher risk of MACCE (hazard ratio 2.356, P=0.006). Preoperative LVMI >200 g/m2was associated with a higher rate of MACCE in patients undergoing AVR for AR.

Transcatheter aortic valve replacement for aortic regurgitation: a systematic review and meta-analysis.

The efficacy and safety of new-generation devices (NGDs) for severe aortic regurgitation (AR) have mostly been based on single-arm studies with limited sample sizes. Our goal was to summarize the current evidence on NGDs and compare the safety and efficacy of 'off-label' and 'on-label' devices in NGDs. We searched MEDLINE, Embase, Cochrane Library, and Scopus for articles on transcatheter aortic valve replacement in patients with AR. A total of 31 studies that included 1851 patients were identified through April 2023. Among these, 1067 (57.6%) patients received treatment with 'on-label' devices (JenaValve and J-Valve). For NGDs, the total device success rate at 30days was 94.5% (on-label: 97.8%, off-label: 89.9%; P<0.001), the all-cause mortality was 4.2% (on-label: 2.6%, off-label: 5.1%; P=0.006), permanent pacemaker implantation (PPI) was 8.8% (on-label: 6.9%, off-label: 18.4%; P<0.001), and the rate of greater-than-mild paravalvular leak (PVL) was 1.2% (on-label: 0.9%, off-label: 3.8%; P=0.003). On-label devices showed significantly better safety and efficacy in terms of the success rate, PPI, greater-than-mild PVL, and 30day mortality than off-label devices.

Progression of non-significant mitral and tricuspid regurgitation after surgical aortic valve replacement for aortic regurgitation

Abstract Background There is limited evidence to guide the management of below moderate mitral and tricuspid regurgitation (MR and TR) during surgical aortic valve replacement (SAVR) for aortic regurgitation (AR). We assessed the long-term progression of these valvulopathies. Methods This is a single-center, retrospective analysis encompassing 7.0 (IQR, 3.4-12.1) years of follow-up after consecutive patients undergoing SAVR between 1995 and 2022. Cases with ≥moderate non-aortic valve disorders or congenital heart disease at baseline and those who had undergone prior or concomitant valvular interventions were excluded. The primary outcome was the incidence of ≥moderate MR or TR on the last documented echocardiogram. Results A total of 184 patients (141 (76.6%) males, median age 64 (IQR, 55-74) years, 134 (72.8%) with pure AR) were included. Of them, 46 (25.0%) underwent both SAVR and ascending aortic replacement. On the last echo study, performed at a median of 5.8 (IQR, 2.7-11.0) years after surgery, ≥moderate MR, ≥moderate TR, and either were evident in 20 (10.9%), 25 (13.5%), and 36 (19.6%) individuals, respectively. Of the latter, above moderate MR or TR occurred in 26 (72.2%). Survival rate was lower among patients with ≥moderate MR or TR on the last echocardiogram (47.2% vs 79.7%, p&amp;lt;0.001). After multivariable analysis, a higher risk for the primary outcome was associated with 4 baseline variables: mild to moderate (vs up to mild) MR or TR (OR 4.17, 95% CI 1.35-12.91, p=0.013), clinical heart failure (OR 7.42, 95% CI 3.47-14.82, p=0.004), atrial fibrillation (OR 3.30, 95% CI 1.10-9.85, p=0.033), and use of composite graft (OR 4.20, 95% CI 1.29-13.61, p=0.017). Conversely, echocardiographic measures of biventricular function and dimensions, aortic valve morphology, and surgical urgency were not predictive of the combined endpoint. Conclusion Among patients undergoing SAVR for AR, new significant MR or TR develop in one-fifth by 6 years and may be predicted by baseline clinical and echocardiographic observations.Risk Factors for the Primary Outcome

Progression of Non-Significant Mitral and Tricuspid Regurgitation after Surgical Aortic Valve Replacement for Aortic Regurgitation.

Little is known about the natural history of non-significant mitral and tricuspid regurgitation (MR and TR) following surgical aortic valve replacement (SAVR) for aortic regurgitation (AR). We retrospectively analyzed 184 patients (median age 64 (IQR, 55-74) years, 76.6% males) who underwent SAVR for AR. Subjects with significant non-aortic valvulopathies, prior/concomitant valvular interventions, or congenital heart disease were excluded. The cohort was evaluated for MR/TR progression and, based on the latter's occurrence, for echocardiographic and clinical indices of heart failure and mortality. By 5.8 (IQR, 2.8-11.0) years post-intervention, moderate or severe MR occurred in 20 (10.9%) patients, moderate or severe TR in 25 (13.5%), and either of the two in 36 (19.6%). Patients who developed moderate or severe MR/TR displayed greater biventricular disfunction and functional limitation and were less likely to be alive at 7.0 (IQR, 3.4-12.1) years compared to those who did not (47.2 vs. 79.7%, p < 0.001). The emergence of significant MR/TR was associated with preoperative atrial fibrillation/flutter, symptomatic heart failure, and above-mild MR/TR as well as concomitant composite graft use, but not with baseline echocardiographic measures of biventricular function and dimensions, aortic valve morphology, or procedural aspects. In conclusion, among patients undergoing SAVR for AR, significant MR/TR developed in one fifth by six years, correlated with more adverse course, and was anticipated by baseline clinical and echocardiographic variables.

Risk factor analysis for aortic dissection after aortic valve replacement in patients with tricuspid aortic valve.

Aortic dilatation concurrent with aortic valve disease is a common condition. However, the incidence of aortic dissection after aortic valve replacement for tricuspid aortic valve has not been fully investigated. Therefore, we performed a risk factor analysis for the incidence of aortic dissection after aortic valve replacement in patients with tricuspid aortic valve. We retrospectively reviewed 599 patients who underwent aortic valve replacement at our hospital between January 2000 and December 2020. We performed a risk factor analysis for the incidence of aortic dissection after aortic valve replacement in patients with tricuspid aortic valve. Seven patients developed late aortic dissections during the follow-up period. All patients with aortic dissection underwent aortic valve replacement for aortic regurgitation. Multivariable analysis revealed that aortic regurgitation was an independent predictor of aortic dissection (p < 0.0001). The mean ascending aortic diameter at aortic valve replacement for aortic regurgitation was significantly greater in patients with aortic dissection than in those without aortic dissection (46 [43.5-46] mm vs. 39 [36-42] mm, p < 0.001). The predictive cutoff value of ascending aortic diameter was indicated using receiver operating characteristic curve analysis; 46.0mm (area under the curve: 0.8987). Freedom rates from aortic dissection in patients with aortic regurgitation and an ascending aortic diameter ≥ 46mm were significantly lower than those in patients with an ascending aortic diameter < 46mm (66.7% vs. 100% at 5years, p < 0.0001). Aortic regurgitation combined with ascending aortic dilatation at aortic valve replacement could be a significant risk factor for late aortic dissection.

Computed tomography anatomical characteristics based on transcatheter aortic valve replacement in aortic regurgitation.

This study analyzed computed tomography (CT) measurement characteristics and anatomical classifications based on transcatheter aortic valve replacement (TAVR) in patients with aortic regurgitation (AR) to establish a preliminary summary of CT anatomical characteristics and to design a novel self-expanding transcatheter heart valve (THV). This single-center retrospective cohort study included 136 patients diagnosed with moderate-to-severe AR at Fuwai Hospital from July 2017 to April 2022. Patients were classified into four anatomical classifications according to dual-anchoring multiplanar measurement of where THV anchoring took place. Types 1-3 were considered candidates for TAVR, whereas type 4 was not. Among 136 patients with AR, there were 117 (86.0%) tricuspid, 14 bicuspid, and five quadricuspid valves. Dual-anchoring multiplanar measurement showed that the annulus was smaller than left ventricular outflow tract (LVOT) at 2, 4, 6, 8, and 10mm on the annulus. The ascending aorta (AA) 40mm was wider than AA 30mm and AA 35mm, but narrower than AA 45mm and AA 50mm. For 10% oversize of the THV, the proportions of the annulus, LVOT, and AA unable to meet the diameter were 22.8%, 37.5%, and 50.0%, respectively, and the proportions of anatomical classification types 1-4 were 32.4%, 5.9%, 30.1%, and 31.6%, respectively. The novel THV could significantly improve the type 1 proportion (88.2%). Existing THVs cannot meet the anatomical characteristics of patients with AR. Conversely, based on anatomical characteristics, the novel THV could theoretically facilitate TAVR.

Medical therapy after surgical aortic valve replacement for aortic regurgitation.

Current clinical guidelines have no specific recommendations regarding medical therapy after surgical aortic valve replacement in patients with aortic regurgitation (AR). We studied the association between medical therapy with renin-angiotensin system (RAS) inhibitors, statins and β-blockers and long-term major adverse cardiovascular events. All patients undergoing valve replacement due to AR between 2006 and 2017 in Sweden and alive 6 months after discharge were included. Time-dependent multivariable Cox regression models adjusted for age, sex, patient characteristics, comorbidities, other medications and year of surgical aortic valve replacement were used. Primary outcome was a composite of all-cause mortality, myocardial infarction and stroke. Subgroup analyses based on age, sex, heart failure, low ejection fraction, hyperlipidaemia and hypertension were performed. A total of 2204 patients were included [median follow-up 5.0 years (range 0.0-11.5)]. At baseline, 68% of the patients were dispensed RAS inhibitors, 80% β-blockers and 35% statins. Dispense of RAS inhibitors and β-blockers declined over time, especially during the first year after baseline, while dispense of statins remained stable. Treatment with RAS inhibitors or statins was associated with a reduced risk of the primary outcome [adjusted hazard ratio (aHR) 0.71, 95% confidence interval (CI) 0.57-0.87 and aHR 0.78, 95% CI 0.62-0.99, respectively]. The results were consistent in subgroups based on age, sex and comorbidities. β-Blocker treatment was associated with an increased risk for the primary outcome (aHR 1.35, 95% CI 1.07-1.70). The results indicate a potential beneficial association of RAS inhibitors and statins as part of a secondary preventive treatment regime after aortic valve replacement in patients with AR. The role of β-blockers needs to be further investigated.

RWD118 Characterisation of Surgical Aortic Valve Replacements for Aortic Regurgitation in Spain During 2016-2019

To describe the trends in the volume, type of aortic valve protheses, and in-hospital resource consumption for patients undergoing isolated surgical aortic valve replacement (SAVR) for aortic regurgitation (AR) in Spain.

One‐year outcome after transcatheter aortic valve replacement for aortic regurgitation: A single‐center study

Presently, there are limited reports in the literature on the postoperative (midterm) clinical outcome for pure aortic regurgitation (AR) following transcatheter aortic valve replacement (TAVR). Between March 2014 and June 2019, a total of 134 high-risk patients with pure, symptomatic severe AR patients were enrolled in the current study. The outcome was assessed according to the Valve Academic Research Consortium-2 criteria. Procedural results, clinical outcomes, and the patients' hemodynamics for a period of 1 year were analyzed. The patient mean was 73.1 ± 6.4 years and 25.4% were female. The average Society of Thoracic Surgeons score was 9.8 ± 5.3%. Procedural success was 97.1% (130/134), and the device success rate was 96.3% (129/134). Five cases were converted to open surgery, while two patients underwent valvular reinterventions (surgical aortic valve replacement for thrombosis and increasing paravalvular regurgitation). The mean aortic valve gradient was 10.2 ± 4.1 mmHg, while the moderate and severe AR was 1.6% at 1 year. Paravalvular regurgitation was none/trivial in 79.8% and mild in 18.5%. The 1-year all-cause mortality rate was 7.4%. At 1 year, the stroke incidence rate was 2.2%,and a pacemaker was implanted in 8.9% of the enrolled patients. In high-risk patients undergoing transapical TAVR for AR, the use of the J-Valve is safe, and effective TAVR should be considered as a reasonable option for high-risk patients with pure AR.

Transcatheter Aortic Valve Replacement for Aortic Regurgitation Caused by Takayasu Arteritis

Aortic regurgitation (AR) in patients with Takayasu arteritis is considered a relatively common clinical condition. Aortic valve replacement as a surgical treatment, however, is known to have a high risk of postoperative prosthetic valve detachment or anastomotic pseudoaneurysm. This pilot study reports on an initial experience with transcatheter aortic valve replacement (TAVR) for AR caused by Takayasu arteritis. The outcome suggests that TAVR may be a potentially feasible alternative treatment option for AR in Takayasu arteritis, especially in relatively older and vulnerable patients.

Transcatheter aortic valve replacement for aortic regurgitation in Asians: TAVR for aortic regurgitation in Asians.

Although surgical aortic valve replacement (SAVR) is currently the recommended intervention for patients with native AR without aortic stenosis, a significant proportion of Asian patients undergo transcatheter aortic valve replacement (TAVR), which has not been studied fully for safety and outcomes. This systematic review aims to examine the characteristics and outcomes of Asian patients with pure native aortic regurgitation (AR) undergoing TAVR. PubMed, Embase, Scopus, Web of Science and Cochrane CENTRAL were systematically searched for randomised controlled trials, observational studies and case reports published from inception to 2 April 2020, involving patients of Asian ethnicity with pure native aortic regurgitation who had undergone TAVR. Our primary outcome was all-cause mortality, with secondary outcomes including all major complications. Five studies (n=274 patients) and eight case reports were included. Device success was reported in 94.9% of the patients, the all-cause mortality rate was 4.4%, 2.5% were converted to SAVR, 1.7% had post-operative paravalvular leak and 6.7% required permanent pacemaker implantation. TAVR has demonstrated acceptable safety and efficacy in Asian patients with pure AR displaying low mortality rates and few adverse outcomes.

Heterogeneous reduction in regional wall stress after aortic valve replacement for aortic regurgitation: a distinct feature from aortic stenosis.

Geometric changes caused by volume reduction early after aortic valve replacement (AVR) for aortic regurgitation (AR) may not be uniform, resulting in varying regional end-systolic wall stress (ESS). This study compared changes in regional ESS between AR and aortic stenosis (AS) patients in the early phase following AVR. Computer-tomographic left ventricular (LV) angiography was performed for 10 patients with AR and 13 with AS before and three months after AVR. Regional ESS at the base, middle, and apex levels, each subdivided into four segments, was calculated based on the Janz equation: ESS = end-systolic LV pressure × local cross-sectional area of LV cavity/that of LV wall. Following AVR, median LV end-diastolic volume index fell from 106 to 69ml/m2 (P = 0.001) in AR and 60 to 46ml/m2 (P = 0.01) in AS patients. Global ESS also declined in both (AR, 186 to 124 kdyne/cm2, P = 0.02; AS, 187 to 108 kdyne/cm2, P < 0.001, respectively). Regional ESS was reduced in all segments in AS patients, accompanied by left ventricular ejection fraction (LVEF) improvement (71-80%, P = 0.02). In contrast, regional ESS in AR patients was heterogeneously reduced, as regional ESS fell significantly in the antero-septal wall but was unchanged in the infero-lateral wall, and LVEF remained unchanged (65 to 62%, P = 0.42). In the early postoperative phase after AVR, the loading condition of the regional LV wall in AR patients was characterized by a heterogeneous reduction in regional ESS in contrast to a uniform decline in AS patients.

Correlation between activated clotting time monitoring and heparin concentration measurement in a patient with antiphospholipid syndrome during cardiac valve surgery: a case report

BackgroundAnticoagulation management of patients with antiphospholipid syndrome (APS) undergoing cardiac surgery is challenging due to the prolongation of activated clotting time (ACT). Currently, no study has compared the utility of ACT monitoring using the Hemochron Jr. Signature+ and that of heparin concentration management using the Hemostasis Management System (HMS) Plus in patients with APS.Case presentationA 71-year-old woman with APS was scheduled to undergo an aortic valve replacement for aortic regurgitation. The ACT was measured using the Hemochron Jr. Signature+, and the heparin concentration was measured concurrently using the HMS Plus. ACT over 480 s corresponded to an adequate heparin concentration during cardiopulmonary bypass. The clinical course was uneventful, and no thrombotic or hemorrhagic complications were observed.ConclusionIn the present patient with APS, the Hemochron Jr. Signature+ was useful as an anticoagulation management during cardiac valve surgery.

The art of aortic valve repair

The art of aortic valve repair

Transcatheter aortic valve replacement in aortic regurgitation: The U.S. experience.

Transcatheter aortic valve replacement (TAVR) can be an effective option for high-risk Aortic Regurgitation (AR) patients. Although international experiences of TAVR for AR are published, U.S. data are limited. This study sought to report the short-term outcomes of TAVR in AR in the U.S. Study cohorts were derived from the Nationwide Inpatient Sample (NIS) and Nationwide Readmissions Database (NRD) 2016-17. TAVR and AR were identified using ICD-10-CM-codes. The key outcomes were all-cause mortality, disabling stroke, valvular complications, complete heart block (CHB)/permanent pacemaker placement (PPM), open-heart surgery, acute kidney injury (AKI) requiring dialysis, and vascular complications. Multivariate logistic regression was used to adjust for confounders. 915 patients from the NIS (male-71%, age ≥65-84.2%) and 822 patients from the NRD (male-69.3%, age ≥65-80.5%) underwent TAVR for AR. The median length of stay (LOS) was 4 days for both cohorts. In-hospital mortality was 2.7%, and 30-day mortality was 3.3%. Disabling strokes were noted in 0.6% peri-procedurally and 1.8% at 30-days. Valve-related complications were 18-19% with paravalvular leak (4-7%) being the most common. Approximately 11% of patients developed CHB and/or needed PPM in both cohorts. In NRD, 2.2% of patients required dialysis for AKI, 1.5% developed vascular complications, and 0.6% required open-heart surgery within 30-days post-procedure. Anemia was predictive of increased overall complications and valvular complications, whereas peripheral vascular disease was a predictor of increased valvular complications and CHB/PPM. TAVR is a promising option in AR. Further studies are necessary for the expansion of TAVR as the standard treatment in AR.

A case of aggressive aortic prosthetic valve endocarditis aggressive caused by Staphylococcus lugdunensis

BackgroundStaphylococcus lugdunensis is a coagulase-negative Staphylococcus species, which are weak pathogenic bacteria generally. However, the acute and severe pathogenicity of Staphylococcus lugdunensis infective endocarditis may be due to the rapid growth of large vegetation and consequent valve destruction.Case presentationThe patient was an 81-year-old male who visited our hospital with chief complaints of low back pain and high fever. Four years before this visit, he had undergone aortic valve replacement for aortic regurgitation. He was found to be hypotensive. Although there is no heart murmur on auscultation and echocardiography revealed negative findings with aortic valve, a blood test showed increases in the white blood cell count and C-reactive protein concentration. On the next day, Gram-positive cocci were detected in a blood culture and echocardiography detected a large vegetation on the prosthetic valve with increased flow velocity. Therefore, he underwent redo aortic valve replacement emergently. Staphylococcus lugdunensis was identified in blood samples and vegetation culture. Consequently, the patient was treated with antibiotics for 5 weeks after the operation and discharged home.ConclusionsWe experienced rapidly progressive prosthetic valve endocarditis caused by Staphylococcus lugdunensis. Hence, Staphylococcus lugdunensis infective endocarditis requires aggressive treatment, and the pathogenicity of this coagulase-negative Staphylococcus with high drug susceptibility should not be underestimated.

Predictors of Long-Term Outcome of Isolated Surgical Aortic Valve Replacement in Aortic Regurgitation With Reduced Left Ventricular Ejection Fraction and Extreme Left Ventricular Dilatation

The management of severe aortic regurgitation (AR) in patients with reduced left ventricular function and extreme left ventricular dilatation presents a therapeutic dilemma. This study aims to assess risk factors of aortic valve replacement (AVR) for these particular population based on its performances. Two hundred twelve severe AR patients accompanied by left ventricular ejection fraction (LVEF) <50% and left ventricular end-diastolic dimension (LVEDD) ≥70 mm who underwent isolated AVR between January 2007 and December 2016 were identified retrospectively. Logistic regression and receiver operating characteristic were used to analyze prognostic indicators for in-hospital mortality while Kaplan-Meier analysis for long-term survival. Mean age was 56 ± 13 years with mean LVEF 40 ± 7% and LVEDD 78 ± 6 mm. In-hospital mortality rate was 7%, and survival rates at 5 and 10 years were 88 ± 4% and 73 ± 10%, respectively. Logistic regression analysis indicated in-hospital mortality was associated with preoperative age and LVEF. Receiver operating characteristic analysis showed LVEF = 35% was the best cut-off value at which to predict in-hospital death. Kaplan-Meier analysis revealed patients with markedly reduced LV function (LVEF <35%) had lower survival rates compared with other patients with moderate LV dysfunction (LVEF 36% to 50%) (1-, 5-, and 10-year: 90 ± 4%, 64 ± 7%, and 55 ± 14%, vs 97 ± 1%, 94 ± 3%, and 76 ± 7%, p <0.001). An age-matched analysis showed similar trend (p = 0.020). In Conclusion, AVR may be unsafe for severe AR patients with markedly reduced LV function (LVEF <35%) and extreme left ventricular dilatation (LVEDD >70 mm) due to poor postoperative early- and long-term outcomes.

TAVR in Patients with Left Ventricular Assist Device: Case Report and Literature Review

ABSTRACT The use of left ventricular assist devices (LVADs) as a bridge-to-transplant or destination therapy in patients with end-stage heart failure has been increased during the last years. However, a potential obstacle to the success of long-term LVAD support is represented by the development of de novo aortic valve lesions leading to aortic regurgitation or, more rarely, to commissural fusion and stenosis. The paper addresses the main pathophysiological factors in the development of aortic valvular regurgitation in patients with LVAD and describes an updated review of all transcatheter aortic valve replacement (TAVR) cases to treat aortic regurgitation currently available. We also report on a case of a patient with a Jarvik 2000 requiring transcatheter aortic valve replacement for aortic regurgitation. The procedure was performed using a 31-mm CoreValve prosthesis. The first check after the positioning of the prosthetic valve revealed a good result. However, a second 10-min check, performed as per protocol at the end of the procedure, showed a sliding of the prosthetic valve downward toward the apex of the left ventricle with a severe periprosthetic regurgitation. Therefore, a second 31-mm CoreValve was deployed within the previous valve prosthesis and a 10-min check revealed a stable position and a mild residual leak. The management of LVAD patients with aortic regurgitation remains challenging. Although transcatheter techniques have demonstrated feasibility in these patients, technical adjustments and further expertise are needed to optimize these procedures.

Can the echocardiographic LV mass equation reliably demonstrate stable LV mass following acute change in LV load?

Limited data are available on performance of the left ventricular (LV) mass equation when there is a dynamic change to LV load. We aimed to test this equation in the immediate post-operative period following aortic valve replacement (AVR) for aortic regurgitation (AR) to see if it would reliably demonstrate stable LV mass before and after surgery. Since LV mass would be unlikely to change in the immediate postoperative period, we hypothesized that a decrease in LV diameter postoperatively would be accompanied by concomitant increases in LV wall thickness as predicted by the LV mass equation. We reviewed echocardiograms of adult patients with AR who underwent AVR from 2007-2017 at Montefiore Medical Center (n=28). Three independent readers performed septal wall thickness (SWT), posterior wall thickness (PWT) and left ventricular internal diameter (LVID) measurements on pre-operative and post-operative echocardiograms. LV masses were calculated using the American Society of Echocardiography (ASE) equation. Post-operatively, LVID decreased from 5.7±1.2 to 4.9±1.0 cm, P<0.001. SWT was noted to increase from 1.08±0.20 to 1.18±0.27 cm, P=0.03, but PWT was unchanged, 1.11±0.21 to 1.16±0.27 cm, P=0.21. Accordingly, the LV mass equation calculated a decrease in LV mass from 266±126 to 232±99 gm, P=0.01. A control group of coronary artery bypass grafting alone (n=14) did not demonstrate any significant change in SWT, LVID, PWT and LV mass measurements. Similar findings were found for all three readers. Following aortic valve replacement for regurgitation, the LV mass equation calculated a reduction in LV mass in the immediate postoperative period. Since an immediate change in LV mass after AVR is unlikely, we feel that these results highlight an important limitation of the mass equation, when used with acutely changing loading conditions.

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

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.