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Left ventricular systolic and diastolic function in aortic stenosis. Prognostic value after valve replacement and
1Department of Thoracic and Cardiovascular Surgery, Skejby Sygehus, Aarhus University Hospital, Denmark.
Insights
Pre-operative left ventricular dysfunction significantly predicts mortality after aortic valve replacement for aortic stenosis. Early intervention before impaired systolic and diastolic function is recommended to improve patient survival.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardiovascular Imaging
Background:
- Aortic stenosis necessitates valve replacement, a procedure where pre-operative patient condition influences outcomes.
- Left ventricular function (LVF) is crucial for cardiac performance, and its impairment may affect surgical results.
Purpose of the Study:
- To assess the prognostic significance of pre-operative left ventricular systolic and diastolic function on early and late mortality following aortic valve replacement for aortic stenosis.
- To explore potential mechanisms underlying these prognostic associations.
Main Methods:
- Prospective recruitment of 91 patients undergoing aortic valve replacement for aortic stenosis.
- Assessment of pre-operative left ventricular systolic function (ejection fraction, peak ejection rate) and diastolic function (fast filling fraction).
- Minimum 5.4-year postoperative follow-up for mortality, with Cox regression analysis for risk factors.
Main Results:
- Subnormal ejection fraction and a fast filling fraction ≤45% were independent predictors of mortality.
- Patients with both impaired systolic and diastolic function faced significantly higher early and late mortality (5-year survival: 50%).
- Concentric hypertrophy was identified as a key mechanism leading to diastolic and subsequent systolic dysfunction.
Conclusions:
- Pre-operative left ventricular systolic and diastolic dysfunction are critical independent risk factors for mortality after aortic valve replacement for aortic stenosis, irrespective of afterload.
- Concentric hypertrophy significantly contributes to adverse outcomes.
- Surgical intervention is advised prior to the development of significant left ventricular dysfunction to optimize survival.
Aims:
The aims of the study were to examine the prognostic value of pre-operative left ventricular systolic and diastolic function on early, and late mortality after valve replacement for aortic stenosis, and to identify possible underlying mechanisms.
Methods And Results:
Ninety-one prospectively recruited consecutive patients with a mean age of 61 years underwent valve replacement for aortic stenosis with concomitant coronary artery bypass grafting in 32 and a minimum postoperative observation period of 5.4 years. There were six early (< or = 30 days postoperatively) and 19 late deaths, and 18 deaths from specific causes (cardiac and prosthetic valve related). Early mortality occurred exclusively among patients with a combined subnormal left ventricular systolic function (subnormal ejection fraction or peak ejection rate, or supranormal time-to-peak ejection--duration of systole ratio) and a subnormal fast filling fraction. In Cox regression models on crude mortality and specific deaths, a subnormal ejection fraction and a fast filling fraction of < or = 45% were the only independent risk factors. Patients with none of these risk factors had normal sex- and age-specific survival, those with any one factor had an early, and those with both factors a massive early and a late excess mortality, with 5-year crude survival of 92%, 77%, and 50%, respectively (P < 0.0001). Systolic wall stress was without prognostic value. Further analyses indicated that impairment of left ventricular function occurred with increasing muscle mass over two phases: (1) diastolic dysfunction characterized by a pattern of severe relative concentric hypertrophy; (2) the addition of systolic dysfunction characterized by a more dilated, less concentric chamber geometry. Coronary artery disease seemed to provoke the latter development sooner.
Conclusions:
Impaired systolic and diastolic left ventricular function, irrespective of afterload, were decisive independent pre-operative risk factors for early as well as late mortality after aortic valve replacement for aortic stenosis. The adverse influence of concentric hypertrophy was the main underlying mechanism. Operative intervention, before impairment of diastolic and systolic function, should be advocated.
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