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Preoperative moderate to severe diastolic dysfunction: a novel Doppler echocardiographic long-term prognostic factor
Peter Gjertsson1, Kenneth Caidahl, Mahmood Farasati
1Department of Clinical Physiology, Cardiovascular Institute, Sahlgrenska University Hospital, Göteborg, Sweden.
Insights
Severe aortic stenosis patients with moderate to severe diastolic dysfunction face increased long-term mortality after valve replacement. This diastolic dysfunction is a key predictor of survival, independent of other factors.
Area of Science:
- Cardiology
- Cardiac Surgery
- Echocardiography
Background:
- Severe aortic stenosis necessitates valve replacement.
- Long-term outcomes depend on various patient and prosthesis factors.
- Diastolic function's role in post-valve replacement survival is not fully understood.
Purpose of the Study:
- To investigate long-term outcomes after aortic valve replacement.
- To assess the impact of prosthesis type and size, left ventricular ejection fraction, diastolic function, and left ventricular mass on survival.
Main Methods:
- Retrospective analysis of 399 patients undergoing valve replacement (1991-1993).
- Diastolic function assessed using Doppler echocardiography, categorized as normal/mild or moderate/severe dysfunction.
- Poisson regression analysis incorporated diastolic function, ejection fraction, age, sex, and time for mortality prediction.
Main Results:
- Overall 12-year survival was 50%.
- Moderate to severe diastolic dysfunction independently predicted late mortality (HR=1.72, P=0.0038).
- Left ventricular ejection fraction, mass, prosthesis type, and size did not predict late mortality.
Conclusions:
- Moderate to severe diastolic dysfunction is an independent predictor of late mortality after aortic valve replacement.
- The prognostic significance of diastolic dysfunction persists and may even increase over time.
- Non-reversible myocardial changes associated with diastolic dysfunction may negatively impact survival.
Objective:
We studied long-term outcomes in severe aortic stenosis and the importance of prosthesis type (mechanical vs biologic) and size, preoperative left ventricular ejection fraction, diastolic function, and left ventricular mass.
Methods:
Patients undergoing valve replacement from 1991 to 1993 (n = 399, 45% women) were included. The diastolic function was evaluated by integrating mitral and pulmonary venous flow data with Doppler echocardiography. The patients were classified as having either normal diastolic function to mild diastolic dysfunction or moderate to severe diastolic dysfunction. Left ventricular ejection fraction and the diastolic function category were incorporated together with age, sex, and time since operation into a Poisson regression model with death as the end point. Prosthesis type and size and left ventricular mass were also investigated.
Results:
The age (mean +/- SD) was 71 +/- 9 years, and the overall survival after 12 years was 50%. Although markedly reduced during the initial 6-month period, mortality risk subsequently increased more than could be explained by age (hazard ratio of 1-year difference = 1.12, P = .0005). The moderate to severe diastolic dysfunction pattern independently predicted late mortality (hazard ratio = 1.72, P = .0038), whereas left ventricular ejection fraction did not (hazard ratio = 0.99, P = .18). The prognostic importance of moderate to severe diastolic dysfunction did not diminish with time; on the contrary, it tended to increase. Mortality after 12 years was not predicted by left ventricular mass (P = .66), prosthesis type (P = .57), or prosthesis size (P = .58).
Conclusion:
This study reveals that moderate to severe diastolic dysfunction in patients with aortic stenosis is an independent predictor of late mortality after valve replacement and that its importance does not decrease with time. Our findings may suggest that moderate to severe diastolic dysfunction implies nonreversible myocardial changes that negatively affect survival.
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