Effect of aortic valve replacement on ventricular recovery and functional class in patients with reduced left ventricular function

Abstract

Objective: The aim of the study was to assess the effects of aortic valve replacement (AVR) in patients with aortic stenosis (AS) or regurgitation (AR) and left ventricular (LV) dysfunction. Patients and methods: Retrospective analysis identified 75 consecutive patients with left ventricular ejection fraction (LVEF) assessed by echocardiography < 40% who underwent AVR for AS (n = 40) or AR (n = 35) between 1994 and 2011. Exclusion criteria were previous myocardial infarction or concomitant valvular disorders other than aortic disease. Follow-up evaluated the New York Heart Association (NYHA) functional class, LVEF and survival rate. Results: Mean ages were respectively 56.5 ± 9.3 and 47.9 ± 11.7 years in AS and AR groups, p = 0.001. Before surgery, 88% and 75% of patients were in NYHA III-IV respectively in AS and AR. In the AS group, the mean LVEF and aortic valve area (AVA) were respectively 32.2% ± 8% and 0.65 ± 0.15 cm2. AR group had a mean LVEF of 33.8 ± 6.7% and a mean LV systolic diameter of 62 ± 8.8 mm. All patients underwent AVR under cardiopulmonary bypass. There were 5 operative deaths (12.5%) in AS group and 6 (17.6%) in AR group, p = 0.57. LVEF increased to 49% ± 14.7% and 51.2% ± 10.9% in the AS and AR groups after echocardiography control. The survival rates at 1, 5 and 10 years were respectively 94.4%, 87% and 80% in AS group and 95.2%, 93% and 89% in AR group. Conclusion: Despite higher perioperative mortality in patients with aortic valve disease (AS or AR) and LV dysfunction, long-term outcome is excellent. We, therefore, conclude that AVR can be performed and it should not be denied to patients on the basis of low EF alone.

 

Share and Cite:

Houssa, M. , Moutakiallah, Y. , Abdou, A. , Hatim, A. , Drissi, M. , Amahzoune, B. , Bekkali, Y. , Benyass, A. and Boulahya, A. (2013) Effect of aortic valve replacement on ventricular recovery and functional class in patients with reduced left ventricular function. World Journal of Cardiovascular Diseases, 3, 543-550. doi: 10.4236/wjcd.2013.39086.

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1] Cannolly, H.M., Oh, J.K., Orszulak, T.A., Osborn, S.L., Roger, V.L., Hodge, D.O., et al. (1997) Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction. Prognostic indicators. Circulation, 95, 2395-2400. http://dx.doi.org/10.1161/01.CIR.95.10.2395
[2] Mandinov, L., Kaufmann, P. and Hess, O.M. (1998) Diagnosis and indication for aortic valve replacement in asymptomatic and symptomatic patients with aortic regurgitation. Herz, 23, 441-447.
http://dx.doi.org/10.1007/BF03043405
[3] Bonow, R.O., Picone, A.L., McIntosh, C.L., Jones, M., Rosing, D.R., Maron, B.J., et al. (1985) Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: Impact of preoperative left ventricular function. Circulation, 72, 1244-1256.
http://dx.doi.org/10.1161/01.CIR.72.6.1244
[4] Wahi, S., Haluska, B., Pasquet, A., Case, C., Rimmermann, C.M. and Marwick, T.H. (2000) Exercise echocardiography predicts development of left ventricular dysfunction in medically and surgically treated patients with asymptomatic severe aortic regurgitation. Heart, 84, 606-614. http://dx.doi.org/10.1136/heart.84.6.606
[5] Powell, D.E., Tunick, P.A., Rosenzweig, B.P., Freedberg, R.S., Katz, E.S., Applebaum, R.M., et al. (2000) Aortic valve replacement in patients with aortic stenosis and severe left ventricular dysfunction. Archives of Internal Medicine, 160, 1337-1341.
http://dx.doi.org/10.1001/archinte.160.9.1337
[6] Czer, L.S., Gray, R.J., Stewart, M.E., De Robertis, M., Chaux, A. and Matloff, J.M. (1988) Reduction in sudden late death by concomitant revascularization with aortic valve replacement. The Journal of Thoracic and Cardiovascular Surgery, 95, 390-401.
[7] Morris, J.J., Schaff, H.V., Mullany, C.J., Rastogi, A., McGregor, C.G., Daly, R.C., et al. (1993) Determinants of survival and recovery of left ventricular function after aortic valve replacement. The Annals of Thoracic Surgery, 56, 22-29.
http://dx.doi.org/10.1016/0003-4975(93)90398-2
[8] Bonow, R.O., Dodd, J.T., Maron, B.J., O’Gara, P.T., White, G.G., McIntosh, C.L., et al. (1988) Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation. Circulation, 78, 1108-1120.
http://dx.doi.org/10.1161/01.CIR.78.5.1108
[9] Lund, O., Flo, C., Jensen, F.T., Nielsen, T.T., Rasmussen, B.S., Hansen, O.K., et al. (1997) Left ventricular systolic and diastolic function in aortic stenosis. Prognostic value after valve replacement and underlying mechanisms. European Heart Journal, 18, 1977-1987.
http://dx.doi.org/10.1093/oxfordjournals.eurheartj.a015209
[10] Corti, R., Benggeli, C., Turina, M., Jenni, R., Luscher, T.F. and Turina, J. (2001) Predictors of long-term survival after valve replacement for chronic aortic regurgitation. Is M-mode echocardiography sufficient? European Heart Journal, 22, 866-873.
http://dx.doi.org/10.1053/euhj.2000.2314
[11] Sharony, R., Grossi, E.A., Saunders, P., Schwartz, C.F., Ciuffo, G.B., Baumann, F.G., et al. (2003) Aortic valve replacement in patients with impaired ventricular function. The Annals of Thoracic Surgery, 75, 1808-1814.
http://dx.doi.org/10.1016/S0003-4975(03)00117-6
[12] Bonow, R.O., Carabello, B.A., Chatterjee, K., De Leon Jr., A.C., Faxon, D.P., Freed, M.D., et al. (2006) ACC/ AHA 2006, guidelines for the management of patients with valvular heart disease: A report of the American college of cardiology/American Heart Association Task Force on practice Guidelines. Circulation, 114, e84-e231.
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.176857
[13] McCarthy, P.M. (2002) Aortic valve surgery in patients with left ventricular dysfunction. Seminars in Thoracic and Cardiovascular Surgery, 14, 137-143.
http://dx.doi.org/10.1053/stcs.2002.32368
[14] Green, G.R. and Miller, D.G. (1997) Continuing dilemmas concerning aortic valve replacement in patients with advanced left ventricular dysfunction. The Journal of Heart Valve Disease, 6, 562-579.
[15] Clavel, M.A., Fuchs, C., Burwash, I.G., Mundigler, G., Dumesnil, J.G., Baumgartner, H., et al. (2008) Predictors of outcomes in low-flow, low-gradient aortic stenosis: Results of the multicenter TOPAS Study. Circulation, 118, S234-S242.
[16] Ross, J. and Braunwalds, E. (1968) Aortic stenosis. Circulation, 38, 61-67.
http://dx.doi.org/10.1161/01.CIR.38.1S5.V-61
[17] Chizner, M.A., Pearle, D.L. and De Leon, A.C. (1980) The natural history of aortic stenosis in adults. American Heart Journal, 99, 419-424.
http://dx.doi.org/10.1016/0002-8703(80)90375-0
[18] Ricci, D.R. and Mason, M.A. (1982) Ventricular performance in chronic aortic regurgitation: Application to the concept of afterload mismatch and preload reserve. Clinical Research, 30, 18A.
[19] Taniguchi, K., Kawamaoto, T., Kuki, S., Masai, T., Mitsuno, M., Nakano, S., et al. (2000) Left ventricular myocardial remodeling and contractile state in chronic aortic regurgitation. Clinical Cardiology, 23, 608-614.
http://dx.doi.org/10.1002/clc.4960230812
[20] Cannolly, H.M., Oh, J.K., Schaff, H.V., Roger, V.L., Osborn, S.L., Hodge, D.O., et al. (2000) Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction. Results of aortic valve replacement in 52 patients. Circulation, 101, 1940-1946.
http://dx.doi.org/10.1161/01.CIR.101.16.1940
[21] Rothenburger, M., Drebber, K., Tjan, T.D., Schmidt, C., Wichter, T., Scheld, H.H., et al. (2003) Aortic valve replacement for aortic regurgitation and stenosis in patients with severe left ventricular dysfunction. European Journal Cardio-Thoracic Surgery, 23, 703-709.
http://dx.doi.org/10.1016/S1010-7940(03)00030-7
[22] Flores-Marin, A., Gomez-Doblas, J.J., Caballero-Borrego, J., Cabrera-Bueno, F., Rodriguez-Bailon, I., Melero, J.M., et al. (2010) Long-term predictors of mortality and functional recovery after aortic valve replacement for severe aortic stenosis with left ventricular dysfunction. Revista Espanola de Cardiología, 63, 36-45.
[23] Rabus, M.B., Kirali, K., Kayalar, N., Yayla-Tuncer, E., Toker, M.E. and Yakut, C. (2009) Aortic valve replacement in isolated severe aortic stenosis with left ventricular dysfunction: Long-term survival and ventricular recovery. Anadolu Kardiyoloji Dergisi, 9, 41-46.
[24] Chukwuemeka, A., Rao, V., Armstrong, S., Ivanov, J. and David, T. (2006) Aortic valve replacement: A safe and durable option in patients with impaired left ventricular systolic function. European Journal CardioThoracic Surgery, 29, 133-138.
http://dx.doi.org/10.1016/j.ejcts.2005.11.028
[25] Bevilaqua, S., Gianetti, J., Ripoli, A., Paradossi, U., Cerillo, A.G., Glauber, M., et al. (2002) Aortic valve disease with severe ventricular dysfunction: Stentless valve for better recovery. The Annals of Thoracic Surgery, 74, 2016-2021.
http://dx.doi.org/10.1016/S0003-4975(02)03981-4
[26] Rediker, D.E., Boucher, C.A., Block, P.C., Akins, C.W., Buckley, M.J. and Fifer, M.A. (1987) Degree of reversibility of left ventricular systolic dysfunction after aortic valve replacement for isolated aortic valve stenosis. The American Journal of Cardiology, 60, 112-118.
http://dx.doi.org/10.1016/0002-9149(87)90996-9
[27] Silver, K., Aurigemma, G., Krendel, S., Barry, N., Ockene, I. and Alpert, J. (1993) Pulmonary artery hypertension in severe aortic stenosis: Incidence and mechanism. American Heart Journal, 125, 146-150.
http://dx.doi.org/10.1016/0002-8703(93)90067-J
[28] Malouf, J., Enriquez-Sarano, M., Pellikka, P.A., Oh, J.K., Bailey, K.R., Chandrasekaran, K., et al. (2002) Severe pulmonary hypertension in patients with severe aortic valve stenosis: Clinical profile and prognostic implications. Journal of the American College of Cardiology, 40, 789-795.
http://dx.doi.org/10.1016/S0735-1097(02)02002-8
[29] Melby, S.J., Moon, M.R., Lindman, B.R., Bailey, M.S., Hill, L.L. and Damiano, R.J. (2011) Impact of pulmonary hypertension on outcomes after aortic valve replacement for aortic valve stenosis. The Journal of Thoracic and Cardiovascular Surgery, 141, 1424-1430.
http://dx.doi.org/10.1016/j.jtcvs.2011.02.028
[30] Levy, F., Laurent, M., Monin, J.L., Maillet, J.M., Pasquet, A., Le Tourneau, T., et al. (2008) Aortic valve replacement for low-flow/low-gradient aortic stenosis. Journal of the American College of Cardiology, 51, 1466-1472.
http://dx.doi.org/10.1016/j.jacc.2007.10.067
[31] Monin, J.L., Monchi, M., Gest, V., Duval-Moulin, A.M., Dubois-Rande, J.L. and Gueret, P. (2001) Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients. Journal of the American College of Cardiology, 37, 2101-2107.
http://dx.doi.org/10.1016/S0735-1097(01)01339-0
[32] Quere, J.P., Monin, J.L., Levy, F., Petit, H., Baleynaud, S., Chauvel, C., et al. (2006) Influence of preoperative left ventricular contractile reserve on postoperative ejection fraction in low-gradient aortic stenosis. Circulation, 113, 1738-1744.
http://dx.doi.org/10.1161/CIRCULATIONAHA.105.568824
[33] Lamb, H.J., Beyerbacht, H.P., De Roos, A., Van Der Laarse, A., Vliegen, H.W., Leujes, F., et al. (2002) Left ventricular remodeling early after aortic valve replacement: Differential effect on diastolic function in aortic valve stenosis and regurgitation. Journal of the American College of Cardiology, 40, 2182-2188.
http://dx.doi.org/10.1016/S0735-1097(02)02604-9
[34] Monin, J.L., Quéré, J.P., Monchi, M., Petit, H., Baleynaud, S., Chauvel, C., et al. (2003) Low-gradient aortic stenosis: Operative risk stratification and predictors for long-term outcome: A multicenter study using dobutamine stress hemodynamics. Circulation, 108, 319-324.
http://dx.doi.org/10.1161/01.CIR.0000079171.43055.46
[35] Tribouilloy, C., Levy, F., Rusinaru, D., Gueret, P., PetitEisenmann, H., Baleynaud, S., et al. (2009) Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography. Journal of the American College of Cardiology, 53, 1865-1873.
http://dx.doi.org/10.1016/j.jacc.2009.02.026
[36] Monin, J.L. and Gueret, P. (2005) Dobutamine hemodynamics for aortic stenosis with left ventricular dysfunction. Annales de Cardiologie et d Angéiologie, 54, 101-111.
[37] Barbosa, M.M., Freire Claudia, M.V., Fenelon Lucia, M.A., Esteves William, A.M., Reis, G. and Nunes Maria do Carmo, P. (2009) Dobutamine stress echocardiography in asymptomatic patients with aortic regurgitation. Arquivos Brasileiros De Cardiologia, 93, 49-57.
[38] Chaliki, H.P., Mohty, D., Avierinos, J.F., Scott, C.G., Schaff, H.V., Tajik, A.J., et al. (2002) Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function. Circulation, 106, 2687-2693.
http://dx.doi.org/10.1161/01.CIR.0000038498.59829.38
[39] Meurs, A.A., Gründemann, A.M., Bezemer, P.D., Geldof, W.C., Zienkowicz, B.S., Ong, S.T., et al. (1985) Early and 8 years results of aortic valve replacement: A clinical study of 232 patients. European Heart Journal, 6, 870-881.
[40] Bhudia, S.K., McCarthy, P.M., Kumpati, G.S., Helou, J., Hoercher, K.J., Rajeswaran, J., et al. (2007) Improved outcomes after aortic valve replacement surgery for chronic aortic regurgitation with severe left ventricular dysfunction. Journal of the American College of Cardiology, 49, 1465-1471.
http://dx.doi.org/10.1016/j.jacc.2007.01.026
[41] Scognamiglio, R., Negut, C., Palisi, M., Fasoli, G. and Dalla-Volta, S. (2005) Long-term survival and functional results after aortic valve replacement in asymptomatic patients with chronic severe aortic regurgitation and left ventricular dysfunction. Journal of the American College of Cardiology, 45, 1025-1030.
http://dx.doi.org/10.1016/j.jacc.2004.06.081
[42] Taniguchi, K., Nakano, S., Kawashima, K., Yakai, K., Kawamoto, T., Sakaki, S., et al. (1990) Left ventricular ejection performance, wall stress and contractile state in aortic regurgitation before and after aortic valve replacement. Circulation, 82, 798-807.
http://dx.doi.org/10.1161/01.CIR.82.3.798
[43] Hanayama, N., Christakis, G.H., Mallidi, H.R., Rao, V., Cohen, G., Goldman, B.S., et al. (2005) Determinants of incomplete left ventricular mass regression following aortic valve replacement. Journal of Cardiac Surgery, 20, 307-313.
http://dx.doi.org/10.1111/j.1540-8191.2005.200485.x
[44] Roman, M.J., Klein, L., Devereux, R.B., Kligfield, P., Niles, N.W., Hochreiter, C., et al. (1989) Reversal of left ventricular dilatation, hypertrophy and dysfunction by valve replacement in aortic regurgitation. American Heart Journal, 118, 553-563.
http://dx.doi.org/10.1016/0002-8703(89)90272-X
[45] Taniguchi, K., Takahashi, T., Toda, K., Matsue, H., Shudo, Y., Shintni, H., et al. (2007) Left ventricular mass: Impact of left ventricular contractile function and its reversibility in patients undergoing aortic valve replacement. European Journal Cardio-Thoracic Surgery, 32, 588-595. http://dx.doi.org/10.1016/j.ejcts.2007.07.003
[46] Carabello, B., Usher, B.W., Hendrix, G.H., Assey, M.E., Crawford, F.A. and Leman, R.B. (1987) Predictors of outcomes for aortic valve replacement in patients with regurgitation and left ventricular dysfunction: A change in measuring stick. Journal of the American College of Cardiology, 10, 991-997.
http://dx.doi.org/10.1016/S0735-1097(87)80335-2
[47] Villari, B., Sossalla, S., Ciampi, Q., Petruzziello, B., Turina, J., Schneider, J., et al. (2009) Persistent diastolic dysfunction late after valve replacement in severe aortic regurgitation. Circulation, 120, 2386-2392.
http://dx.doi.org/10.1161/CIRCULATIONAHA.108.812685
[48] Vaquette, B., Corbineau, H., Laurent, B., Lelong, B., Langanay, T., De Place, C., et al. (2005) Valve replacement in patients with critical aortic stenosis and depressed left ventricular function: Predictors of operative risk, left ventricular function recovery, and long term outcome. Heart, 91, 1324-1329.
http://dx.doi.org/10.1136/hrt.2004.044099
[49] Otto, C.M. (2006) Valvular aortic stenosis: Disease severity and timing of intervention. Journal of the American College of Cardiology, 47, 2141-2151.
http://dx.doi.org/10.1016/j.jacc.2006.03.002
[50] Hanayama, N., Christakis, G.T., Mallidi, H.R., Joyner, C.D., Fermes, S.E., Morgan, C.D., et al. (2002) Patient prosthesis mismatch is rare after aortic valve replacement: Valve size may be irrelevant. The Annals of Thoracic Surgery, 73, 1822-1829.
http://dx.doi.org/10.1016/S0003-4975(02)03582-8
[51] Blais, C., Dumesnil, J.G., Baillot, R., Simard, S., Doyle, D. and Pibarot, P. (2003) Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement. Circulation, 108, 983-988.
http://dx.doi.org/10.1161/01.CIR.0000085167.67105.32
[52] Tamas, E., Nylander, E. and Olin, C. (2005) Are patients with isolated chronic aortic regurgitation operated in time? Analysis of survival data over a decade. Clinical Cardiology, 28, 329-332.
http://dx.doi.org/10.1002/clc.4960280705
[53] Pibarot, P. and Dumesnil, J.G. (2006) Prosthesis-patient mismatch: Definition, clinical impact, and prevention. Heart, 92, 1022-1029.
http://dx.doi.org/10.1136/hrt.2005.067363
[54] Mohty, D., Malouf, J.F., Girard, S.E., Schaff, H.V., Grill, D.E., Enriquez-Sarano, M.E., et al. (2006) Impact of prosthesis-patient mismatch on long term survival in patients with small St Jude Medical mechanical prostheses in the aortic position. Circulation, 113, 420-426.
http://dx.doi.org/10.1161/CIRCULATIONAHA.105.546754

Copyright © 2024 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.