Pre-operative subnormal ejection fraction and fast filling fraction ≤45% significantly reduced 5-year survival after aortic valve replacement (50% with both factors vs 92% with neither; P<0.0001).
Cohort (n=91)
Does pre-operative impaired left ventricular systolic and diastolic function predict early and late mortality in patients undergoing aortic valve replacement for aortic stenosis?
Pre-operative impairment of both systolic and diastolic left ventricular function strongly predicts early and late mortality after aortic valve replacement, suggesting intervention should occur before these impairments develop.
Absolute Event Rate: 50% vs 92%
p-value: p=<0.0001
AIMS: The aims of the study were to examine the prognostic value of pre-operative left ventricular systolic and diastolic function on early, and late mortality after valve replacement for aortic stenosis, and to identify possible underlying mechanisms. METHODS AND RESULTS: Ninety-one prospectively recruited consecutive patients with a mean age of 61 years underwent valve replacement for aortic stenosis with concomitant coronary artery bypass grafting in 32 and a minimum postoperative observation period of 5.4 years. There were six early (< or = 30 days postoperatively) and 19 late deaths, and 18 deaths from specific causes (cardiac and prosthetic valve related). Early mortality occurred exclusively among patients with a combined subnormal left ventricular systolic function (subnormal ejection fraction or peak ejection rate, or supranormal time-to-peak ejection--duration of systole ratio) and a subnormal fast filling fraction. In Cox regression models on crude mortality and specific deaths, a subnormal ejection fraction and a fast filling fraction of < or = 45% were the only independent risk factors. Patients with none of these risk factors had normal sex- and age-specific survival, those with any one factor had an early, and those with both factors a massive early and a late excess mortality, with 5-year crude survival of 92%, 77%, and 50%, respectively (P < 0.0001). Systolic wall stress was without prognostic value. Further analyses indicated that impairment of left ventricular function occurred with increasing muscle mass over two phases: (1) diastolic dysfunction characterized by a pattern of severe relative concentric hypertrophy; (2) the addition of systolic dysfunction characterized by a more dilated, less concentric chamber geometry. Coronary artery disease seemed to provoke the latter development sooner. CONCLUSIONS: Impaired systolic and diastolic left ventricular function, irrespective of afterload, were decisive independent pre-operative risk factors for early as well as late mortality after aortic valve replacement for aortic stenosis. The adverse influence of concentric hypertrophy was the main underlying mechanism. Operative intervention, before impairment of diastolic and systolic function, should be advocated.
Lund et al. (Tue,) conducted a cohort in Aortic stenosis (n=91). Subnormal ejection fraction and fast filling fraction <= 45% vs. No risk factors (normal LV function) was evaluated on 5-year crude survival (p=<0.0001). Pre-operative subnormal ejection fraction and fast filling fraction ≤45% significantly reduced 5-year survival after aortic valve replacement (50% with both factors vs 92% with neither; P<0.0001).