Aortic Valve Replacement in True Severe Aortic Stenosis with Low Gradient and Low Ejection Fraction
DOI:
https://doi.org/10.1532/HSF98.20061039Abstract
Objective. The results of aortic valve replacement are uncertain among patients with severe aortic stenosis, reduced left ventricular ejection fraction, and low mean transvalvular gradient. The aim of the present study was to report on 27 patients who underwent surgery for aortic stenosis with left ventricular ejection fraction ?30% and mean transvalvular gradient <30 mmHg.
Methods. The study was performed between January 2000 and December 2005. Twenty-seven patients with aortic stenosis with a calculated valve area <1.0 cm2, aortic mean transvalvular gradient <30 mmHg, and ejection fraction ?30% were studied. Exclusion criteria were coronary artery disease, concomitant valvular operation, previous aortic valve replacement, or more than moderate aortic valve regurgitation. Preoperative clinical, echocardiography and dobutamine echocardiography, cardiac catheterization and coronary angiography, and operative data were recorded in all patients. Patients who were diagnosed with true aortic stenosis were divided into 2 groups according to left ventricular ejection fraction changes during dobutamine echocardiography, 16 with recruitable myocardium (group 1) versus 11 without (group 2).
Results. One patient from group 2 died. The functional capacities of all of the patients in group 1 significantly improved in the postoperative period (P = .001). All of the patients except for 1 in group 1 had improved left ventricular ejection fraction after the operation (P <.001). The comparison of the preoperative and postoperative functional status of these patients in group 2 was also statistically significant (P = .001). The 10 of the 11 patients in group 2 who were alive had left ventricular ejection fraction value changes that were not significant statistically (P = .096). The comparison of the improvement of functional capacities of the groups revealed a significant difference; that is, the improvement was higher in group 1 (P = .039).
Conclusion. Left ventricular ejection fraction and functional capacity improved after aortic valve replacement in patients with left ventricular dysfunction, low mean transvalvular gradient, and aortic valve replacement in these patients has acceptable mortality rates with significantly improved functional status.
References
Aronow WS, Ahn C, Kronzon I, Nanna M. 1994. Prognosis of patients with heart failure and unoperated severe aortic valvular regurgitation and relation to ejection fraction. Am J Cardiol 74:286-8.nCarabello BA. 1991. Timing of surgery in mitral and aortic stenosis. Cardiol Clin 9:229-38.nAronow WS, Ahn C, Kronzon I, Nanna M. 1993. Prognosis of congestive heart failure in patients aged ?62 years with unoperated severe valvular aortic stenosis. Am J Cardiol 72:846-8.nCarabello BA. 1997. Timing of valve replacement in aortic stenosis: moving closer to perfection. Circulation 95:2241-3.nCarabello BA, Green LH, Grossman W, Cohn LH, Koster JK, Collins JJ Jr. 1980. Hemodynamic determinants of prognosis of aortic valve replacement in critical aortic stenosis and advanced congestive heart failure. Circulation 62:42-8.nConnolly HM, Oh JK, Orszulak TA, et al. 1997. Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction: prognostic indicators. Circulation 95:2395-400.nConnolly HM, Oh JK, Schaff HV, et al. 2000. Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction result of aortic valve replacement in 52 patients. Circulation 101:1940-6.nGradman AH, Harbison MA, Berger HJ, et al. 1981. Ventricular arrhythmias late after aortic valve replacement and their relation to left ventricular performance. Am J Cardiol 48:824-31.nHenry WL, Bonow RO, Borer JS, et al. 1980. Evaluation of aortic valve replacement in patients with valvular aortic stenosis. Circulation 61:814-25.nMonin JL, Monchi M, Gest V, Duval-Moulin AM, Dubois-Rande JL, Gueret P. 2001. Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients: risk stratification by low-dose dobutamine echocardiography. J Am Coll Cardiol 37:2101-7.nObadia JF, Eker A, Rescigno G, Flamens C, Chassignolle JF. 1995. Valvular replacement for aortic stenosis on patients in NYHA class III and IV. Early and long term results. J Cardiovase Surg (Torino) 36:251-6.nPantely G, Morton M, Rahimtoola SH. 1978. Effects of successful, uncomplicated valve replacement on ventricular hypertrophy, volume, and performance in aortic stenosis and in aortic incompetence. J Thorac Cardiovasc Surg 75:383-91.nRoss JJ. 1976. Afterload mismatch and preload reserve: a conceptual framework for the analysis of ventricular function. Prog Cardiovasc Dis 18:255-64.nSchwammenthal E, Vered Z, Moshkowitz Y, et al. 2001. Dobutamine echocardiography in patients with aortic stenosis and left ventricular dysfunction predicting outcome as a function of management strategy. Chest 119:1766-77.nSharma UC, Barenbrug P, Pokharel S, Dassen WRM, Pinto YM, Maessen JG. 2004. Systematic review of the outcome of aortic valve replacement in patients with aortic stenosis. Ann Thorac Surg 78:90-5.nSmith N, McAnulty JH, Rahimtoola SH. 1978. Severe aortic stenosis with impaired left ventricular function and clinical heart failure: results of valve replacement. Circulation 58:255-64.nTask Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease). 1998. ACC/AHA guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association. J Am Coll Cardiol 32:1486-588.nPaul S, Mihaljevic T, Rawn JD, Cohn LH, Byrne JG. 2004. Aortic valve replacement in patients with severely reduced left ventricular function. Cardiology 101:7-14.nPereira JJ, Lauer MS, Bashir M, et al. 2002. Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction. J Am Coll Cardiol 39:1356-63.nYilik L, Ozsoyler I, Yakut N, et al. 2004. Passive infusion: a simple delivery method for retrograde cardioplegia. Tex Heart Inst J 31:392-7.nMorris JJ, Schaff HV, Mullany CJ, et al. 1993. Determinants of survival and recovery of left ventricular function after aortic valve replacement. Ann Thorac Surg 56:22-9.nNishimura RA, Grantham JA, Connoly HM, Schaff HV, Higano ST, Holmes DR Jr. 2002. Low-output, low-gradient aortic stenosis in patients with depressed left ventricular systolic function the clinical utility of the dobutamine challenge in the catheterization. Lab Circ 106:809-13.n
