Early surgery versus conventional treatment for asymptomatic severe aortic regurgitation with normal ejection fraction and left ventricular dilatation

Background An accepted concept in septic shock is that preload adaptation by acute left ventricular dilatation, when occurring spontaneously or with the aid of volume loading, permits maintenance of an adequate cardiac output, leading to final recovery. From a physiologic point of view, this concept appears debatable because a normal pericardium exerts a restraining action on a normal heart. Methods During a 26-month period, the authors investigated, by transesophageal echocardiography, 40 patients hospitalized in their unit for an episode of septic shock. Transesophageal echocardiography was performed in the first hours after admission, proceeded by correction of any hypovolemia, and stabilization of arterial pressure by vasoactive agent infusion if necessary. Left ventricular dimensions were obtained in long- and short-axis views, permitting calculation of left ventricular ejection fraction (long axis) and fractional area contraction (short axis). Stroke index was simultaneously measured by the Doppler technique. Results Stroke index was strongly correlated with both echocardiographic left ventricle ejection fraction (r = 0.75; P < 0.0001) and left ventricle fractional area contraction (r = 0.76; P < 0.0001), whereas it was independent of echocardiographic left ventricle diastolic dimensions. Conclusions The transesophageal echocardiography study was unable to confirm the reality of the concept of early preload adaptation by left ventricular dilatation in septic shock. Conversely, because left ventricular volume always remained in a normal range after correcting hypovolemia, systolic function was the unique determinant of stroke index in septic shock.

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Severe aortic regurgitation and reduced left ventricular ejection fraction: Outcomes after isolated aortic valve replacement and combined surgery

The Journal of Heart and Lung Transplantation ◽

10.1016/j.healun.2009.09.018 ◽

2010 ◽

Vol 29 (4) ◽

pp. 445-448 ◽

Cited By ~ 6

Author(s):

Alessandro Sionis ◽

Ana García-Alvarez ◽

María Ángeles Castel ◽

Marco Cordero ◽

Miguel Josa ◽

...

Keyword(s):

Left Ventricular Ejection Fraction ◽

Aortic Valve ◽

Ejection Fraction ◽

Aortic Valve Replacement ◽

Aortic Regurgitation ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Combined Surgery ◽

Ventricular Ejection Fraction ◽

Severe Aortic Regurgitation

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Longitudinal strain in patients with severe aortic regurgitation: superiority to ejection fraction for detection of myocardial dysfunction

European Heart Journal ◽

10.1093/ehjci/ehaa946.1868 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J.C Reil ◽

G.-H Reil ◽

N Necker ◽

J Borer ◽

H.H Sievers ◽

...

Keyword(s):

Ejection Fraction ◽

Aortic Regurgitation ◽

Longitudinal Strain ◽

Myocardial Dysfunction ◽

Global Longitudinal Strain ◽

Left Ventricular ◽

Stroke Work ◽

Indication For Surgery ◽

Severe Aortic Regurgitation ◽

Normal Lvef

Abstract Objectives The aim of the study was to analyse LV systolic function and mechanical energetics in asymptomatic patients with severe aortic regurgitation (AR) to seek a new hemodynamic concept for timing for surgery. Background Current guidelines suggest surgery for patients with severe AR including clinical symptoms, subnormal LV ejection fraction (EF), or markedly abnormal left ventricular dimensions. However, the optimal measure to detect intrinsic myocardial systolic dysfunction in the presence of normal LVEF remains elusive. Methods Strain and echo-derived single beat pressure-volume analyses were performed in cohorts with severe AR without indication for surgery (ARNS; LVEDD <70mm, EF >50%, n=41), with indication for surgery (ARS; n=19) and in healthy, age-matched controls (C; n=20). Additionally, end-systolic elastance (Ees=LV contractility), stroke work (SW) and total energy (PVA) were calculated. Results Patients with ARNS demonstrated significant depression of LV contractility vs. C: Ees (1.5mmHg/ml ±0.7 vs. 2.25mmHg/ml ±0.7; p<0.001), despite comparable ejection fractions (EF: 0.56±0.05 vs. 0.60±0.07; p=0.10). Accordingly, global longitudinal strain (GLS) was decreased (−16.0±2.5% vs. −21.5±2%; p<0.001), end-diastolic volume markedly enlarged (236ml ±90 vs. 136ml ±30; p<0.001), as were PVA and SW indicating waste of energy. The correlation of GLS vs. Ees was good (r=−0.68; p<0.001). Results of ARS-patients were consistently worse. Conclusion Patients with severe AR and normal LVEF showed depressed LV contractility and waste of energy when assessed by Ees and GLS, both correlating well with each other. Hence, GLS may outperform LV dimensions for predicting timing for surgery and clinical outcomes in AR patients. Funding Acknowledgement Type of funding source: None

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Postoperative prognosis and reversibility of the left ventricular function for aortic regurgitation with marked left ventricular dilatation.

Japanese Journal of Cardiovascular Surgery ◽

10.4326/jjcvs.16.253 ◽

1987 ◽

Vol 16 (4) ◽

pp. 253-256

Author(s):

J. Hayashi

Keyword(s):

Left Ventricular Function ◽

Ventricular Function ◽

Aortic Regurgitation ◽

Left Ventricular ◽

Ventricular Dilatation ◽

Postoperative Prognosis ◽

Left Ventricular Dilatation

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Abstract 4691: Endomyocardial Dysfunction in Patients with Severe Aortic Regurgitation and Preserved Ejection Fraction: A Speckle Tracking Echocardiographic Study

Circulation ◽

10.1161/circ.118.suppl_18.s_931 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Yoshihiro Seo ◽

Tomoko Ishizu ◽

Noriko Iida ◽

Tomoko Machino ◽

Ryou Kawamura ◽

...

Keyword(s):

Ejection Fraction ◽

Aortic Regurgitation ◽

Speckle Tracking ◽

Myocardial Dysfunction ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Separate Analysis ◽

Ventricular Ejection Fraction ◽

Severe Aortic Regurgitation ◽

Control Subjects

Potential myocardial dysfunction may be present in patients with significant aortic regurgitation (AR) and preserved left ventricular ejection fraction (LVEF). Newly developed software for speckle tracking imaging (STI) allows separate analysis of endo- and epimyocardial strain. The aim of this study was to assess the relationship between endo- and epimyocardial radial strain (RS) distribution and AR severity in identifying the potential myocardial dysfunction in patients with significant AR and LVEF>50%, and its correlation with postoperative LV function. We studied 47 patients with AR and 26 control subjects. Degree of AR was classified according to standard echocardiographic criteria as moderate in 16 and severe in 23 patients. STI was analyzed with the new software (Toshiba Medical Systems, Tokyo, Japan). For STI analysis, an endocardial and epicardial border line were each manually traced at end-systole on a short-axis B-mode image at the mid-ventricular level; peak RS of total, endomyocardium, and epicardium were automatically calculated. Endomyocardial RS was reduced in patients with severe AR compared to control subjects and patients with moderate AR (Figure ). Postoperative changes in LVEF were well correlated with the ratio of baseline endomyocardial RS to epimyocardial RS (n=21, r=−0.69, p<0.001). Endomyocardial RS was reduced in patients with severe AR. Assessment of STI-derived RS distribution may be useful to identify potential myocardial dysfunction and postoperative LV functional deterioration in patients with severe AR and preserved EF.

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