A retrospective comparative study was designed to determine whether the transvalvular gradient has a predictive value in the assessment of operative outcome in patients with severe aortic stenosis and poor left ventricular function.
From a surgical database, a series of 30 consecutive patients, who underwent isolated aortic valve replacement for severe aortic stenosis with depressed left ventricular (LV) function (EF < 40%), were enrolled in the study and divided into two groups according to the mean transvalvular gradient (TVG): LG(low gradient)-Group < 40 mmHg (n = 13), and HG(high gradient)-Group > 40 mmHg (n = 17). Both groups were then comparatively assessed with respect to perioperative organ functions and mortality.
Both groups were well matched with respect to the preoperative clinical status. LG-Group had a larger aortic valve area, higher LVEDP, larger LVESD and LVEDD, and higher mean pulmonary pressures. The immediate postoperative outcome, hospital morbidity and mortality did not differ significantly among the groups.
In patients with severe aortic stenosis and poor LV function, the mean transvalvular gradient, although corresponds to reduced LV performance, has a limited prognostic value in the assessment of surgical outcome. Generally, operating on this select group of patients is safe.
In patients with severe aortic stenosis (AS) scheduled for aortic valve replacement (AVR), the operative risk as well as the late postoperative outcome increases with the onset of LV systolic and diastolic dysfunction [1,2]. As the results of AVR in patients with severely reduced LV function and low TVG are uncertain, this patient subset still remains the most controversial in terms of decision making for surgery .
Few data are available on the immediate postoperative and long-term outcome in patients with isolated severe AS and poor LV function, especially in regard to the severity of TVG.
We tested the hypothesis that AVR in patients with isolated severe AS and poor LV function, the mean TVG has no impact on immediate postoperative outcome. Indications for surgery in the light of current opinions published in the literature are discussed.
- Connolly HM, Oh JK, Orszulak TA, Osborn SL, Roger VL, Hodge DO, Bailey KR, Seward JB, Tajik AJ: Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction: prognostic indicators. Circulation 1997, 95(10):2395-2400.
- Lund O, Flo C, Jensen K, Emmertsen K, Nielsen TT, Rasmussen BS, Hansen OK, Pilgaard HK, Kristensen LH: Left ventricular systolic and diastolic function in aortic stenosis. Prognostic value after valve replacement and underlying mechanisms. Eur Heart J 1997, 18:1977-1987.
- Connolly HM, Oh JK, Schaff HV, Roger VL, Osborn SL, Hodge DO, Tajik AJ: Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction. Circulation 2000, 101(16):1940-1949.
- Hardman SM, Pfeiffer KP, Kenner T, Noble MI, Seed WA: Analysis of left ventricular contractile behaviour during atrial fibrillation. Basic Res Cardiol 1994, 89(5):438-445.
- Monin JL, Quere JP, Monchi M, Petit H, Baleynaud S, Chauvel C, Pop C, Ohlmann P, Lelguen C, Dehant P, Tribouilloy C, Gueret P: Low gradient aortic stenosis. Operative risk stratification and predictors for long-term outcome: a multicentre study using dobutamine stress hemodynamics. Circulation 2003, 108:319-324.
- Monin JL, Gueret P: Calcified aortic stenosis with left ventricular dysfunction and low transvalvular gradients. Must one reject surgery in certain cases? Arch Mal Coeur Vaiss 2003, 96:864-870.
- Schwammenthal E, Vered Z, Moshkovitz Y, Rabinowitz B, Ziskind Z, Smolinski AK, Feinberg MS: Dobutamine echocardiography in patients with aortic stenosis and left ventricular dysfunction. Predicting outcome as a function of management strategy. Chest 2001, 119:1766-1777.
- Powell DE, Tunick PA, Rosenzweig BP, Freedberg RS, Katz ES, Applebaum RM, Perez JH, Kronzon I: Aortic valve replacement in patients with aortic stenosis and severe ventricular dysfunction. Arch Intern Med 2000, 160:1337-1341.
- Tarantini G, Buja P, Scognamiglio R, Razzolini R, Gerosa G, Isabella G, Ramondo A, Iliceto S: Aortic valve replacement for aortic regurgitation and stenosis in patients with severe left ventricular dysfunction. Eur J Cardiothorac Surg 2003, 23:703-709.
- Monin JL, Monchi M, Gest V, Duval-Moulin AM, Dubois-Rande JL, Gueret P: Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients. Risk stratification by low-dose dobutamine echocardiography. J Am Coll Cardiol 2001, 37:2101-2107.
- Quere JP, Monin JL, Levy F, Petit H, Baleynaud S, Chauvel C, Pop C, Ohlmann P, Lelguen C, Dehant P, Gueret P, Tribouilloy C: Influence of preoperative left ventricular contractile reserve on postoperative ejection fraction in low-gradient aortic stenosis. Circulation 2006, 113(14):1738-1744.
- Bonandi L, Hess OM, Turina M, Krayenb─é─¢hl HP: Late systolic stress-diameter relation in patients with aortic valve disease before and after valve replacement. Basic Res Cardiol 1984, 79(4):413-422.
- Krayenb─é─¢hl HP, Hess OM, Monrad ES, Schneider J, Mall G, Turina M: Function and structure of the failing left ventricular myocardium in aortic valve disease before and after valve replacement. Basic Res Cardiol 1991, 86(suppl 3):175-185.
- Brogan WC III, Grayburn PA, Lange RA, Hillis LD: Prognosis after valve replacement in patients with severe aortic stenosis and a low transvalvular pressure gradient. J Am Coll Cardiol 1993, 21:1657-1660.
- Nishimura RA, Grantham JA, Connolly HM, Schaff HV, Higano ST, Holmes DR Jr: Low-output, low-gradient aortic stenosis in patients with depressed left ventricular systolic function: the clinical utility of dobutamine challenge in the catheterization laboratory. Circulation 2002, 106:809-813.
- Rothenburger M, Drebber K, Tjan TD, Schmidt C, Wichter T, Scheld HH, Deiwick M: Aortic valve replacement for aortic regurgitation and stenosis in patients with severe left ventricular dysfunction. Eur J Cardiothorac Surg 2003, 23:703-709.
- Ross Jr: Afterload mismatch in aortic and mitral valve disease: implications for surgical therapy. J Am Coll Cardiol 1985, 5:811-826.
- Monin JL, Gueret P: Dobutamine hemodynamics for aortic stenosis with left ventricular dysfunction. Ann Cardiol Angeiol 2005, 54(3):107-111.
- Haghi D, Suselbeck T, Fluechter S, Kalmar G, Schroder M, Kaden JJ, Poerner T, Borggrefe M, Papavassiliou T: A hybrid approach for quantification of aortic valve stenosis using cardiac magnetic resonance imaging and echocardiography: comparison to right heart catheterization and standard echocardiography. Clin Res Cardiol 2006, 95:162-167.