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Preoperative identification of patients likely to have left ventricular dysfunction after aortic valve replacement.
M H Hwang1, K E Hammermeister, C Oprian
1Cardiology Department, Hines Veterans Administration Hospital 60141.
Insights
Preoperative left ventricular dysfunction is the strongest predictor of poor outcomes after aortic valve replacement. Early surgery for aortic stenosis or regurgitation is recommended before significant left ventricular dysfunction occurs.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardiovascular Imaging
Background:
- Left ventricular dysfunction (LVD) can persist after aortic valve replacement (AVR).
- Identifying predictors of LVD post-AVR is crucial for patient management.
Purpose of the Study:
- To identify preoperative and intraoperative variables predicting LVD six months after AVR.
- To inform surgical timing and patient selection for AVR.
Main Methods:
- Analysis of data from 180 patients in the Veterans Administration Cooperative Study on Valvular Heart Disease.
- Univariate and multivariate analyses of preoperative and intraoperative variables.
- Cardiac catheterization data at six months postoperatively were used to define LVD.
Main Results:
- Preoperative left ventricular ejection fraction was the strongest predictor of LVD post-AVR in patients with aortic stenosis.
- For aortic regurgitation, preoperative ejection fraction and left ventricular systolic pressure were key predictors.
- Preoperative myocardial infarction and left ventricular systolic pressure predicted LVD in mixed aortic valve disease.
Conclusions:
- Preoperative left ventricular dysfunction is the primary determinant of LVD after AVR.
- Patients with moderate to severe aortic stenosis or regurgitation should undergo AVR before significant LVD develops.
- Early AVR can improve left ventricular function, but normalization is not always achieved.
Abstract:
The purpose of this study was to identify preoperative and intraoperative variables predictive of left ventricular dysfunction 6 months after aortic valve replacement. Patients were considered to have postoperative left ventricular dysfunction if the end-diastolic-volume index was greater than or equal to 101 ml/m2 or if the ejection fraction was less than or equal to 0.50. Data from 180 patients entered into the Veterans Administration Cooperative Study on Valvular Heart Disease who had technically satisfactory cardiac catheterizations 6 months postoperatively were analyzed by a series of univariate and multivariate analyses. For the 88 patients with preoperative aortic stenosis, the most powerful predictor of postoperative left ventricular dysfunction in the final multivariate model was preoperative left ventricular ejection fraction (p = 0.0001), followed by preoperative myocardial infarction (p = 0.012), aortic valve gradient (p = 0.020), and incomplete coronary revascularization (p = 0.059). Abnormal preoperative left ventricular ejection fraction had a sensitivity of 72% and a specificity of 82% in identifying patients with postoperative left ventricular dysfunction. Preoperative left ventricular systolic-volume index greater than or equal to 40 ml/m2 had a similar sensitivity and specificity (79% and 84%, respectively). For the 36 patients with aortic regurgitation, preoperative left ventricular ejection fraction was again the most powerful predictor of postoperative left ventricular dysfunction (p = 0.013), followed by left ventricular systolic pressure (p = 0.038) and arteriovenous oxygen difference (p = 0.054). For the 56 patients with mixed aortic stenosis and regurgitation, left ventricular systolic pressure (p = 0.007) and preoperative myocardial infarction (p = 0.022) were the variables predictive of postoperative left ventricular dysfunction. Although many patients with preoperative left ventricular dysfunction experience improved left ventricular performance after aortic valve replacement, performance does not always return to normal. For patients with either aortic stenosis or regurgitation, the strongest predictor of postoperative left ventricular dysfunction is preoperative dysfunction. These data support the concept that patients with moderate or severe aortic stenosis or regurgitation should be operated on before the onset of significant left ventricular dysfunction.