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Echocardiographic predictors of left ventricular dysfunction after aortic valve surgery in children with chronic
Elif Seda Selamet Tierney1, Dana Gal, Kimberly Gauvreau
1Pediatric Heart Center, Lucile Packard Children’s Hospital, Stanford University School of Medicine, 750 Welch Road, Suite 305, Mail Code: 5731, Palo Alto, CA 94304, USA. tierneys@stanford.edu
Insights
Identifying children at risk for left ventricular dysfunction after aortic valve surgery is crucial. Lower systolic function and increased dilation predict this risk, guiding surgical decisions in pediatric aortic regurgitation.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Echocardiography
Background:
- Postoperative left ventricular dysfunction (LV dysfunction) poses a significant risk in adults with chronic aortic regurgitation.
- Limited data exists on pediatric risk factors for LV dysfunction following aortic valve surgery.
- Published guidelines aim to mitigate this risk, highlighting the need for pediatric-specific insights.
Purpose of the Study:
- To identify preoperative risk factors for postoperative left ventricular dysfunction in children with chronic aortic regurgitation.
- To establish predictors for adverse LV remodeling and function after aortic valve surgery in pediatric patients.
- To inform clinical decision-making and risk stratification in pediatric aortic regurgitation management.
Main Methods:
- Retrospective study of 53 pediatric patients (age ≤18 years) with chronic aortic regurgitation undergoing aortic valve surgery.
- Inclusion criteria: moderate aortic regurgitation, mild aortic stenosis, no other valve disease/shunt, and available echocardiograms pre- and post-operatively (≥6 months).
- Primary outcome: postoperative LV dysfunction defined as ejection fraction z-score < -2. Analyzed preoperative echocardiographic parameters including LV dimensions, volumes, and systolic function indices.
Main Results:
- Patients with postoperative LV dysfunction (n=10) exhibited significantly higher preoperative LV end-diastolic/systolic volumes and dimensions, and lower systolic function indices compared to those with normal function.
- Preoperative ejection fraction z-score < -1 was sensitive (89%) but not specific (58%) for predicting LV dysfunction.
- Left ventricular end-systolic diameter z-score ≥ 5 was highly specific (95%) but less sensitive (60%).
- A combination of shortening fraction z-score < -1 or end-systolic diameter z-score ≥ 5 demonstrated the best predictive performance (Area Under Curve = 0.819).
Conclusions:
- Reduced left ventricular systolic function indices and increased LV dilation severity are key preoperative indicators of risk for postoperative LV dysfunction in pediatric patients undergoing aortic valve surgery.
- These identified risk factors in children are comparable to those in adult populations, though specific threshold values may differ.
- These findings can aid in preoperative risk stratification and surgical planning for pediatric aortic regurgitation.
Objective:
Postoperative left ventricular dysfunction is associated with poor prognosis in adults with severe chronic aortic regurgitation and published practice guidelines aim to minimize this risk. However, only limited information exists in pediatrics. The goal of this study was to define preoperative risk factors for postoperative left ventricular dysfunction in children with chronic aortic regurgitation.
Methods:
Patients fulfilling the following criteria were included in this study: (1) age at preoperative echocardiogram ≤18 years; (2) ≥moderate aortic regurgitation; (3) ≤mild aortic valve stenosis; (4) no additional valve disease/shunt; (5) underwent aortic valve surgery for aortic regurgitation; and (6) available preoperative and ≥6-month postoperative echocardiograms with adequate information. Primary outcome was postoperative left ventricular dysfunction defined as ejection fraction z-score < -2.
Results:
Median ages at diagnosis and surgery of the 53 eligible patients were 6.9 (0.04-17.2) and 13 years (1.2-22.4), respectively. Compared with patients whose postoperative left ventricular ejection fraction was normal, those with left ventricular ejection fraction z-score < -2 (n = 10) had significantly higher preoperative left ventricular end-diastolic and systolic volumes and dimensions and lower indices of systolic function. Preoperative left ventricular ejection fraction z-score < -1 was the most sensitive (89%; confidence interval [CI] 52, 100) but least specific (58%; CI 41, 73), whereas left ventricular end-systolic diameter z-score ≥ 5 was the most specific (95%; CI 84, 99) but least sensitive (60%; CI 26, 88) outcome identifier. A combination of shortening fraction z-score < -1 or end-systolic diameter z-score ≥ 5 best identified postoperative left ventricular dysfunction with an area of 0.819 under the receiver-operator characteristic curve.
Conclusion:
Lower indices of left ventricular systolic function and severity of dilation identify children at risk for postoperative left ventricular dysfunction after aortic valve surgery. These identifiers are similar to predictors defined in adult patients albeit with different threshold values.
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