Abstract
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.
Keywords
cardiac - cardiomyopathy - heart failure - heart valve - surgery
