Aortic valve replacement: a safe and durable option in patients with impaired left ventricular systolic function

Background: The natural history of aortic valve disease associated with ventricular dysfunction is dismal. Aortic valve replacement (AVR) is associated with increased mortality in patients with left ventricular dysfunction and the long-term outcome in these patients is not well-known. We evaluated perioperative outcomes and long-term results in patients with impaired left ventricular systolic function undergoing AVR. Methods: Retropective analysis identified 132 consecutive patients with a left ventricular ejection fraction (LVEF) < 40% who underwent AVR with or without concomitant coronary artery bypass grafting (CABG) between 1990 and 2003. Patients with other valve pathology were excluded. Results: Ages ranged from 29 to 94 years (mean 63 AE 12), and 117 patients (89%) were male. Preoperatively, 82% were in NYHA III-IV. Sixty patients (45%) underwent AVR for severe aortic stenosis (AS) whilst 72 (55%) had aortic insufficiency (AI). In the AS group, the mean LVEF and aortic valve area were 26 AE 4% and 0.8 AE 0.4 cm 2 , respectively. AI patients had a mean LVEF of 27 AE 6% and a mean left ventricular end systolic diameter of 52 AE 9 mm. Fifty-seven (43%) required concomitant CABG. There were only three perioperative deaths (2.3%) and no strokes. One patient (0.8%) had postoperative renal failure, and one suffered a myocardial infarct. Nine patients (6.9%) required a postoperative IABP. LVEF increased to 29 AE 10% and 34 AE 12% after six months in the AS and AI groups, respectively. The mean follow-up period was 6.1 years and no differences between the AS and AI groups were observed with respect to either perioperative or long-term outcomes. Overall survival was 96%, 79% and 55% at 1, 5 and 10 years, respectively. Conclusions: The long asymptomatic course of AS and AI means that many patients have impaired ventricular function at diagnosis. This study demonstrates that AVR in such patients can be performed with low perioperative morbidity and mortality. The outlook after surgery is excellent. A 10-year-survival of 55% compares favourably with heart transplantation and particularly with medical therapy. AVR is a safe, effective and durable option, which should not be denied to patients on the basis of low LVEF alone.