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Time course of regression of left ventricular hypertrophy after aortic valve replacement
E S Monrad1, O M Hess, T Murakami
1Medical Policlinic, Division of Cardiology, University Hospital, Zurich, Switzerland.
Insights
Myocardial hypertrophy regression after aortic valve replacement is a slow, multi-year process. Cardiac function improves over time, even years after surgery, as the heart muscle mass normalizes.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardiovascular Physiology
Background:
- Myocardial hypertrophy is an adaptive response to increased hemodynamic stress, commonly seen in aortic stenosis and aortic insufficiency.
- Left ventricular hypertrophy can lead to impaired cardiac function and increased risk of adverse cardiovascular events.
- Aortic valve replacement (AVR) is the definitive treatment for severe aortic valve disease, aiming to relieve hemodynamic stress.
Purpose of the Study:
- To evaluate the time course and extent of regression of left ventricular myocardial hypertrophy following AVR.
- To assess the impact of myocardial remodeling on cardiac function in the long term after AVR.
- To compare the recovery of cardiac structure and function in patients with aortic stenosis versus aortic insufficiency.
Main Methods:
- Prospective study of 21 patients undergoing AVR for aortic stenosis or insufficiency.
- Serial echocardiographic and hemodynamic assessments were performed preoperatively, at an intermediate postoperative period (1.6 years), and late postoperatively (8.1 years).
- Results were compared with 11 age- and sex-matched control subjects.
Main Results:
- AVR resulted in significant hemodynamic improvement, including reduced left ventricular end-diastolic volume and filling pressures.
- Left ventricular muscle mass index decreased by 31% at the intermediate study and a further 13% by the late study.
- While left ventricular muscle mass normalized by the late study, cardiac index and ejection fraction showed continued improvement between the intermediate and late postoperative assessments.
Conclusions:
- Regression of myocardial hypertrophy after AVR is a gradual process extending over many years.
- Continued improvement in cardiac function can occur during myocardial remodeling, suggesting that hypertrophied myocardium operates at a reduced capacity.
- Long-term follow-up is crucial to fully understand the benefits of AVR and the process of cardiac recovery.
Abstract:
To assess the time course and extent of regression of myocardial hypertrophy after removal of the inciting hemodynamic stress, 21 patients with either aortic stenosis or aortic insufficiency were studied preoperatively, after an intermediate period (1.6 +/- 0.5 years), and late (8.1 +/- 2.9 years) after aortic valve replacement, and results were compared with those in 11 control patients. After aortic valve replacement there was significant hemodynamic improvement, with a fall in the left ventricular end-diastolic volume index (164 +/- 73 to 105 +/- 35 ml/m2, p less than .01), a fall in left heart filling pressure (19 +/- 9 to 12 +/- 5 mm Hg, p less than .01), and maintenance of the cardiac index (3.3 +/- 0.8 to 3.5 +/- 0.8 liters/min/m2, NS) and left ventricular ejection fraction (60 +/- 13% to 64 +/- 10%, NS). By the late study the cardiac index (4.0 +/- 0.6 liters/min/m2, p less than .01) and left ventricular ejection fraction (66 +/- 15%, p less than .05) had further increased and were significantly greater than before surgery. For the group as a whole, the left ventricular muscle mass index fell 31% after surgery by the time of the intermediate postoperative study (174 +/- 38 vs 120 +/- 29 g/m2, p less than .01), and a further 13% from the intermediate to the late study (105 +/- 32 g/m2, p less than .05). At the preoperative study left ventricular muscle mass index was greatest in those patients with aortic insufficiency (191 +/- 36 g/m2), and greater in those with aortic stenosis (158 +/- 33 g/m2) than in control subjects (85 +/- 9 g/m2, p less than .05). At the intermediate postoperative study left ventricular muscle mass index remained significantly higher in both those with preoperative aortic insufficiency (128 +/- 29 g/m2) and those with stenosis (114 +/- 27 g/m2) than in the control subjects (p less than .01). By the time of the late postoperative study there were no longer any significant differences in left ventricular muscle mass index. Thus, the regression of myocardial hypertrophy is a process that occurs over many years after correction of the primary hemodynamic abnormality. As this process of myocardial remodeling occurs, continued improvement in cardiac function may occur, and the improvement occurring between the intermediate and late postoperative studies at a slight but constant afterload excess (inherent in the relative stenosis of the aortic prosthesis) suggests that the hypertrophied myocardium is operating at a reduced level compared with normal myocardium.