Left ventricular performance in aortic valve replacement

Abstract Aims Aortic stenosis (AS) is characterized both by progressive valve narrowing and left ventricular remodelling response. Myocardial fibrosis has significant functional consequences and is the key pathological process driving left ventricular decompensation. Furthermore, studies suggest that myocardial fibrosis is irreversible, despite surgical aortic valve replacement (SAVR). The study aims to define the association between myocardial fibrosis and long-term diastolic and atrial function after SAVR, which are both markers of poor clinical outcomes. Methods We evaluated patients with isolated AS and no-coronary artery disease referred for SAVR in 2015. All of them received a biological valve and a left ventricular biopsy was performed at the time of surgery. Clinical and echocardiographic evaluation was performed before surgery and after about 6 years, including fully automated 2D speckle tracking analysis software (TomTec). Atrial function was evaluated with PALS, PACS, and LAVi/septal a’ TDI. Results Nineteen patients completed the follow-up and formed the study cohort, age 72 ± 6 years, 42% female, ejection fraction 63 ± 6.4%, mean fibrosis 26.4 ± 12.7%. Significant myocardial fibrosis (> 33%) was found in 13/19 patients (68%). Although similar at baseline, after 5.6±0.5 years, PACS was significantly higher in patients with low myocardial fibrosis (13.7±4.2 vs. 8.0±3.8, P=0.01), the same trends were observed for PALS (24.1±7.9 vs. 17.0±6.6, P=0.07) and LAVi/septal a’TDI (5.4±1.3 vs. 7.4±2.8, P=0.06). The diastolic profile at long term follow-up was also significantly worsened in patients with LV fibrosis: E/A 0.9±0.3 vs. 1.3±0.4 P= 0.03 and E/e’ 10.6±3.3 vs. 16.6±4.5 P=0.01). Conclusions Myocardial fibrosis at the time of SAVR strongly influences long-term diastolic Doppler profile and atrial function with potentially harmful consequences on clinical status and ventricular performance.

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Patient Outcome and Valve Performance Following a Second Aortic Valve Homograft Replacement

Circulation ◽

10.1161/circ.100.suppl_2.ii-42 ◽

1999 ◽

Vol 100 (suppl_2) ◽

Author(s):

K. Hasnat ◽

E. J. Birks ◽

J. Liddicoat ◽

J. K. F. Hon ◽

S. Edwards ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Left Ventricular ◽

Actuarial Survival ◽

Ventricular Performance ◽

Term Survival ◽

Tissue Degeneration ◽

Actuarial Survival Rate ◽

Aortic Homograft

Background —Homograft valves offer many advantages; however, there is concern about their use in second aortic valve replacement because of the complexity of the procedure and the possibility of accelerated degeneration. Methods and Results —One hundred and forty-four patients underwent a second aortic homograft replacement between 1973 and 1997 (mean follow-up 6.5±5 years, range 1 to 20 years). Eighty-three were male, and 61 were female, aged 17 to 77 years, mean 49.0 years. All patients had undergone previous aortic valve replacement with a homograft. The indication for reoperation was aortic regurgitation in 75 patients (52.1%), aortic stenosis in 28 (19.4%), and mixed aortic valve disease in 41 (28.5%). Root replacement was performed in 54 patients (38%) and subcoronary in 90 (62.5%). Early mortality was 3.4%. The actuarial survival rate was 93% and 82% at 5 and 10 years, respectively. Freedom from tissue degeneration was 96% and 80% at 5 and 10 years, respectively, and freedom from reoperation was 97% and 82% at 5 and 10 years, respectively. Conclusions —This study shows that a second aortic valve homograft replacement results in good early and long-term survival. Accelerated degeneration does not occur. Left ventricular performance is improved, and earlier surgery could further improve outcome, indicating that an aortic homograft is a safe, durable option for patients requiring a second aortic valve replacement.

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