The outcomes of aortic valve replacement in patients with aortic stenosis and reduced left ventricular contractility

Background and Hypothesis: The sensitivity of LVH analysis by ECG voltage criteria in patients with severe aortic valve stenosis undergoing trans-catheter aortic valve replacement (TAVR) has not yet been studied. LVH is expected in the TAVR population and would be reflected in voltage criteria by ECG. Methods: A retrospective chart review was conducted in 176 consecutive TAVR patients without ventricular-paced rhythm. ECG data was collected and analyzed by Sokolow-Lyon and Cornell Voltage criteria. Results were compared to transthoracic echocardiogram. Analyses of variation, correlation, chi-square, and logistic regression were used. The study was approved by the institutional IRB. Results: Sokolow-Lyon and Cornell Voltage criteria for LVH were present and concordant in 19% (33 of 176) of patients; in 49% (86 of 176) of patients, neither criteria was suggestive for LVH. Only 19% (34 of 176) of patients had LVH by Cornell Voltage and 13% (23 of 176) by Sokolow-Lyon criteria, indicative of poor concordance between these two commonly used ECG criteria for LVH (p<0.0001). Ejection fraction, aortic valve gradient, aortic valve area, COPD, PVD, prior stroke, dyslipidemia, and hypertension did not affect the prevalence of LVH by either or both criteria. Women (p<0.01) and patients with rhythm other than atrial fibrillation (p<0.0053) were more likely to have voltage criteria for LVH, while older adults were more likely to meet criteria for LVH. Concordant LVH criteria were noted in patients 84.6 +/- 7.2 years of age, while patients without LVH by ECG voltage criteria were significantly younger at 80.21 +/- 8.1 years of age (p<0.007). Conclusion: The presence of LVH by Sokolow-Lyon and Cornell ECG voltage criteria poorly correlates with the presence of LVH and critical aortic stenosis in TAVR patients. Women are more likely to have voltage criteria for LVH. Therefore, ECG may not be a suitable method of screening patients with severe aortic stenosis for LVH, especially in men.

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Abstract 121: Improvement in Functional Mitral Regurgitation After Isolated Aortic Valve Replacement for Aortic Insufficiency

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.121 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Griffin Boll ◽

Frederick Y Chen

Keyword(s):

Aortic Valve ◽

Mitral Regurgitation ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Aortic Insufficiency ◽

Left Ventricular ◽

Functional Mitral Regurgitation ◽

Reverse Remodeling ◽

Lv Remodeling

Objective: Aortic insufficiency (AI) can lead to left ventricular (LV) remodeling characterized by dilation and increased LV mass. This remodeling can cause altered mitral valve coaptation and functional mitral regurgitation (FMR). While there is growing evidence that aortic valve replacement (AVR) for aortic stenosis promotes sufficient ventricular reverse remodeling that FMR improves or resolves, this effect is not well characterized for patients with AI. Methods: All cases of AVR for AI that were performed at a single center between January 2003 and December 2015 were reviewed. Cases with any concomitant procedures, any degree of aortic stenosis, any evidence of ischemic etiology, absence of mitral regurgitation, or significant primary mitral pathology were excluded from analysis. The primary outcome was change in FMR after isolated AVR. Secondary outcomes included change in LV ejection fraction (EF), left atrial (LA) dimension, and change in end-diastolic and –systolic LV dimensions. Two-tailed paired t-test was used to evaluate for difference between the two time points. Results: Over the course of 13.4 years, 31 cases of isolated aortic valve replacement for pure aortic insufficiency with concurrent functional mitral regurgitation were identified. 54.8% (17/31) of cases had some evidence of bacteremia or aortic vegetations at time of surgery, with 41.9% (13/31) of cases completed urgently. Postoperatively, FMR was improved in 74.2% (23/31) of the patients, and decreased by a mean 1.0 ± 0.8 grades (1.6 ± 0.8 vs 0.6 ± 0.7, p < 0.001). There was no significant change in LV EF (50.5 ± 13.4 vs. 50.2 ± 12.9, p = 0.892) or LA dimension (42.5 ± 7.2 vs 40.7 ± 5.9, p = 0.341), but there were significant reductions in the dimension of the LV at end-diastole (56.7 ± 7.1 vs 47.7 ± 8.5, p < 0.001) and end-systole (38.5 ± 9.7 vs 34.0 ± 8.3, p = 0.011). Conclusions: Significant reduction in ventricular size and subsequent improvement in functional mitral regurgitation is expected after isolated aortic valve replacement for pure aortic insufficiency.

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Abstract 2066: Does Mitral Regurgitation Regress After Aortic Valve Replacement For Aortic Stenosis ? A Prospective Multicenter Study

Circulation ◽

10.1161/circ.116.suppl_16.ii_447-c ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Philippe Unger ◽

Danièle Plein ◽

Bernard Cosyns ◽

Guy Van Camp ◽

Olivier Xhaët ◽

...

Keyword(s):

Aortic Valve ◽

Mitral Regurgitation ◽

Aortic Stenosis ◽

Ejection Fraction ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Left Ventricular ◽

Aortic Valve Area ◽

Regurgitant Volume ◽

Lv Ejection Fraction

Background: Mitral regurgitation (MR) is common in patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS). Whether its severity may decrease after AVR remains controversial. Previous studies were mainly retrospective and the degree of MR was assessed at best semi-quantitatively. This study sought to prospectively and quantitatively assess how AVR may affect MR severity. Methods: Patients with AS scheduled for isolated AVR and presenting holosystolic MR which was not considered for replacement or repair were included. Previous mitral valve surgery; severe aortic regurgitation and poor acoustic windows were excluded. Thirty-five patients (mean age 77±7 years) were studied before (median 1, range 1– 41 days) and after AVR (median 7, range 4 –19 days). All patients underwent a comprehensive echocardiographic examination; MR was assessed by Doppler echocardiography using color flow mapping of the regurgitant jet and the PISA method. No patient had prolapsed or flail mitral leaflet as mechanism of MR. Results: Preoperative maximal and mean transaortic pressure gradients and aortic valve area were 74±26 mmHg, 44±16 mmHg, and 0.57±0.18 cm 2 , respectively. Left ventricular (LV) ejection fraction increased from 49±16 % to 55±15 % after AVR (p<0.001). LV end-diastolic volume decreased from 91±32 ml to 77±30 ml (p<0.001).The ratio of MR jet to left atrial area decreased from 30±16% to 20±14% (p<0.001). MR effective regurgitant orifice (ERO) and regurgitant volume decreased from 10±5 mm 2 to 8±6 mm 2 (p=0.015) and from 19±10 ml to 11±9 ml (p<0.0001). The decrease in ERO and in regurgitant volume was similar in patients with preserved or depressed LV ejection fraction (≤45 %) (2±3 vs 3±6 mm 2 and 7±9 vs 8±7 ml; p=NS, respectively). Conclusions: AVR is associated with an early postoperative reduction of the quantified degree of MR. This mainly results from a decrease in regurgitant volume and only modestly from a reduction in ERO, emphasizing the contributing role of the decrease in driving pressure accross the mitral regurgitant orifice.

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