Persistence of Reduced Left Ventricular Function after Aortic Valve Surgery for Aortic Valve Regurgitation: Bicuspid versus TricuspidFunding No funding was received for this article.
30 December 2018
13 May 2019
12 July 2019 (online)
Objective Long-term prognosis of patients with aortic regurgitation (AR) and reduced left ventricular ejection fraction (LVEF) who undergo aortic valve surgery (AVS) is unknown. Due to the congenital origin, bicuspid aortic valve (BAV) morphotype might be associated with a more severe cardiomyopathy. We aimed to evaluate the LVEF recovery after aortic valve replacement (AVR) surgery in patients with AR and reduced preoperative LVEF.
Methods This retrospective analysis included 1,170 consecutive patients with moderate to severe AR who underwent AVS at our institution between January 2005 and April 2016. Preoperative echocardiography revealed 154 (13%) patients with predominant AR and baseline LVEF < 50%. A total of 60 (39%) patients had a BAV (BAV group), while the remaining 94 (61%) patients had a tricuspid morphotype (tricuspid aortic valve [TAV] group). Follow-up protocol included clinical interview using a structured questionnaire and echocardiographic follow-up.
Results A total of 154 patients (mean age 63.5 ± 12.4 years, 71% male) underwent AVS for AR in the context of reduced LVEF (mean LVEF 42 ± 8%). Fifteen (10%) patients had a severely reduced preoperative LVEF ≤ 30%. Mean STS (Society of Thoracic Surgeons) score was 1.36 ± 1.09%. Mean follow-up was comparable between both the study groups (BAV: 50 ± 40 months vs. TAV: 40 ± 38 months, p = 0.140). A total of 25 (17%) patients died during follow-up. Follow-up echocardiography demonstrated similar rate of postoperatively reduced LVEF in both groups (i.e., 39% BAV patients vs. 43% TAV patients; p = 0.638). Cox's regression analysis showed no significant impact of BAV morphotype (i.e., as compared with TAV) on the postoperative LVEF recovery (odds ratio [OR]: 1.065; p = 0.859). Severe left ventricular (LV) dysfunction at baseline (i.e., LVEF ≤ 30%) was a strong predictor for persistence of reduced LVEF during follow-up (OR: 3.174; 95% confidence interval: 1.517–6.640; p = 0.002). Survival was significantly reduced in patients with persisting LV dysfunction versus those in whom LVEF recovered (log rank: p < 0.001).
Conclusion Our study demonstrates that reduced LVEF persists postoperatively in 40 to 45% patients who present with relevant AR and reduced LVEF at baseline. Postoperative LVEF recovery is independent of aortic valve morphotype (i.e., BAV vs. TAV). Severe LV dysfunction (LVEF ≤ 30%) at baseline is a strong predictor for persistence of reduced LVEF in patients with AR and results in significantly reduced long-term survival.
Presented at the 47th Annual Meeting of the German Society of Thoracic and Cardiovascular surgery in February 2018.
- 1 Iung B, Baron G, Butchart EG. , et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J 2003; 24 (13) 1231-1243
- 2 Falk V, Baumgartner H, Bax JJ. , et al; ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2017; 52 (04) 616-664
- 3 Nishimura RA, Otto CM, Bonow RO. , et al; American College of Cardiology; American College of Cardiology/American Heart Association; American Heart Association. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 2014; 148 (01) e1-e132
- 4 Disha K, Espinoza A, Rouman M, Secknus MA, Kuntze T, Girdauskas E. Long-term recovery of reduced left ventricular ejection fraction after aortic valve replacement in patients with bicuspid aortic valve disease. Thorac Cardiovasc Surg 2016; 64 (05) 418-426
- 5 Brown ML, Schaff HV, Suri RM. , et al. Indexed left ventricular dimensions best predict survival after aortic valve replacement in patients with aortic valve regurgitation. Ann Thorac Surg 2009; 87 (04) 1170-1175 , discussion 1175–1176
- 6 Cox DA, Walton K, Bartz PJ, Tweddell JS, Frommelt PC, Earing MG. Predicting left ventricular recovery after replacement of a regurgitant aortic valve in pediatric and young adult patients: is it ever too late?. Pediatr Cardiol 2013; 34 (03) 694-699
- 7 Wang Y, Shi J, Li F, Wang Y, Dong N. Aortic valve replacement for severe aortic regurgitation in asymptomatic patients with normal ejection fraction and severe left ventricular dilatation. Interact Cardiovasc Thorac Surg 2016; 22 (04) 425-430
- 8 Wang Y, Jiang W, Liu J. , et al. Early surgery versus conventional treatment for asymptomatic severe aortic regurgitation with normal ejection fraction and left ventricular dilatation. Eur J Cardiothorac Surg 2017; 52 (01) 118-124
- 9 Schiller NB, Shah PM, Crawford M. , et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 1989; 2 (05) 358-367
- 10 Ponikowski P, Voors AA, Anker SD. , et al; Authors/Task Force Members; Document Reviewers. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016; 18 (08) 891-975
- 11 Enriquez-Sarano M, Tajik AJ. Clinical practice. Aortic regurgitation. N Engl J Med 2004; 351 (15) 1539-1546
- 12 Bonow RO, Lakatos E, Maron BJ, Epstein SE. Serial long-term assessment of the natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function. Circulation 1991; 84 (04) 1625-1635
- 13 Rothenburger M, Drebber K, Tjan TD. , et al. Aortic valve replacement for aortic regurgitation and stenosis, in patients with severe left ventricular dysfunction. Eur J Cardiothorac Surg 2003; 23 (05) 703-709 , discussion 709
- 14 Chaliki HP, Mohty D, Avierinos JF. , et al. Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function. Circulation 2002; 106 (21) 2687-2693
- 15 Fedak PW, Verma S, David TE, Leask RL, Weisel RD, Butany J. Clinical and pathophysiological implications of a bicuspid aortic valve. Circulation 2002; 106 (08) 900-904
- 16 Demir M. Left ventricular systolic and diastolic function in subjects with a bicuspid aortic valve without significant valvular dysfunction. Exp Clin Cardiol 2013; 18 (01) e1-e4
- 17 Amano M, Izumi C, Imamura S. , et al. Pre- and postoperative predictors of long-term prognosis after aortic valve replacement for severe chronic aortic regurgitation. Circ J 2016; 80 (12) 2460-2467
- 18 Zhang Z, Yang J, Yu Y. , et al. Preoperative ejection fraction determines early recovery of left ventricular end-diastolic dimension after aortic valve replacement for chronic severe aortic regurgitation. J Surg Res 2015; 196 (01) 49-55