Valve replacement in aortic insufficiency with left ventricular dysfunction.

Abstract

Patients [17], ages 14-74 yr, with severe, isolated aortic insufficiency and reduced ejection fraction (0.25-0.49) underwent aortic valve replacement between Jan. 1973 and July 1977. Three had coronary artery disease and also underwent coronary bypass surgery. By New York Heart Association criteria, 1 patient was functional class IV, 7 were class III, 7 were class II and 2 were class I. Left ventricular (LV) end-diastolic pressure was 19 .+-. 2 mm Hg (mean .+-. SEM). LV end-diastolic volume index (218 .+-. 18 ml/m2), end-systolic volume index (124 .+-. 11 ml/m2) and LV mass index (240 .+-. 10 g/m2) were increased in all patients. Mean velocity of circumferential fiber shortening (mean Vcf) (0.75 .+-. 0.05 circ[circles]/s) was depressed in all patients. LV ejection fraction averaged 0.43 .+-. 0.02. There were no operative deaths; 1 patient had a perioperative myocardial infarction and 1 developed complete atrioventricular block. Five late deaths occurred, including 2 patients who were not anticoagulated and died within the 1st yr from severe prosthetic valve obstruction. Actuarially determined 3 yr survival is 61 .+-. 15%. Of the late survivors, 6 are class I, 5 are class II and 1 is class III. Patients [10] who were restudied 14.5 .+-. 3 mo. after surgery had satisfactory prosthetic function. In these 10 patients, LV end-diastolic pressure decreased from 16 .+-. 3 to 10 .+-. 2 mm Hg, LV end-diastolic volume index decreased from 209 .+-. 15 to 155 .+-. 17 ml/m2, LV end-systolic volume index decreased from 118 .+-. 10 to 82 .+-. 14 ml/m2 and LV mass decreased from 234 .+-. 11 to 170 .+-. 16 g/m2. LV volumes returned to normal in only 2 patients, and none had normalization of LV mass. Ejection fraction increased slightly in the restudied patients (0.43 .+-. 0.03 to 0.49 .+-. 0.04; 0.05 < P < 0.10); it increased more than 15% in 5 patients and in 4 of these it returned to normal. Mean Vcf increased from 0.72 .+-. 0.08 to 0.95 .+-. 0.11 circ/s (P < 0.05), but became normal in only 2 patients. Aortic valve replacement can be performed with acceptable risk in patients with severe aortic insufficiency and moderately severe impairment of LV function. Functional class was improved or maintained in late survivors, LV systolic pump function improved in 50% of patients, and there was consistent (but usually incomplete) regression of LV dilatation and hypertrophy even in patients who did not improve their ejection fraction.