AORTIC REGURGITATION: IMPACT OF PREOPERATIVE SYMPTOMS FOR POST-VALVE REPLACEMENT SURVIVAL ON PROGNOSTICATION FROM MYOCARDIAL CONTRACTILITY


Jeffrey S. Borer, M.D., State University of New York Downstate Medical Center, New York, NY, USA

Background: Both preoperative symptoms and severe preoperative myocardial contractility deficit predict survival among patients (pts) undergoing aortic valve replacement (AVR) for aortic regurgitation (AR). The interactive effects of these predictors are unknown.

Methods: Among 66 consecutively studied pts with severe AR and AVR (age 49±15 yrs at AVR, 86% male), we determined pre-AVR symptom status as New York Heart Association Functional Class (FC). We also calculated contractility as pre-AVR change [△] in LVEF from rest to exercise [ex] adjusted for △ in end-systolic wall stress [ESS] from rest to ex [△EF-△ESS] using combined echocardiographic and radionuclide cineangiographic data. We related previously published severe contractility deficit (△EF-△ESS=17) and FC 2-4 symptoms to late post-AVR survival.

Results: During 15 yr followup, 22 pts died (15 of cardiovascular cause). Cox model analysis revealed a relation between both pre-AVR △EF-△ESS and symptoms on post AVR death (p=.001[all causes], p=.029 [cardiovascular]). Log rank test comparisons, among FC-2-4 pts, △EF-△ESS deficit =17 (severe) conferred a ~3-fold increase in avg annual mortality risk vs. pts without this deficit.

Conclusions: The prognostic importance of preoperative symptoms is modulated by the concomitant presence of a severe contractility deficit. Pts with both characteristics are at high risk for late postoperative death and should be closely monitored after AVR.