Aim: 1. To evaluate the effect of aortic valve replacement (AVR) on long term evolution of the left ventricular (LV) systolic and diastolic performance, comparing patients (pts) with aortic stenosis (AS) to pts with aortic regurgitation (AR). 2. To identify the independent predictors for persistence or recurrence of the congestive heart failure (HF) late after isolated AVR.
Methods: 10 years prospective study on 802 pts undergoing AVR for AS (456pts) or AR (346pts). Pts were evaluated clinically and echocardiographically (including TDI) preoperatively and yearly till 10 years postoperatively.The effect of demographic, comorbid, and valve-related variables on the composite outcome of NYHA class III/IV symptoms or congestive heart failure death after surgery was evaluated with stratified log-rank tests, Cox proportional hazard models and logistic regression. Multivariable analyses were adjusted for age and gender and included left ventricular ejection fraction (LVEF)≤35%, restrictive left ventricular diastolic filling pattern (LVDFP), renal insufficiency and logistic EuroSCORE ≥20%.
Results: 1. At 5 years postoperatively, restrictive LVDFP persisted at 37.19% of the pts from AS group and at 65.79% pts from AR group. Also, LVEF≤35% was found at 21.95% pts from AS group and at 56.52% pts from AR group.
2. Freedom from congestive HF or cardiovascular death at 5 and 10 years, was significantly higher in AS group (86,84% and 76,32%) compared with AR group (77,46% and 60,4%) (p<0.05).
3. Regression analysis identified as independent predictors for persistence or recurrence of HF late after AVR: preoperative AR (RR=21.2), E/E'ratio>12 (RR=25.1), LA dimension index >30mm/m2 (RR=8.2), LV enddiastolic volume (LVEDV) >200cm3 (RR=8.6), preoperative NYHA class IV (RR=9.2), atrial fibrillation (AF) (RR=6.2), obstructive pulmonary disease (COPD) (RR=28.6), smoking (RR=18.7), prosthesis mismatch (RR=12.5) and 2 degree mitral regurgitation (MR) (RR=12.6) (p<0.05)
Conclusions: 1. LV systolic and diastolic dysfunction is reversible mostly after AVR for AS than for AR, both in the early and late postoperative term.
2. On long term, freedom from congestive HF or cardiovascular death was significantly higher in AS group. The presence of restrictive LVDFP had a significant impact on outcomes, decreasing long-term survival and increasing hospitalizations rates, mostly in preoperative AR.
3. The main predictors for persistence or recurrence of HF late after AVR were: preoperative AR, restrictive LVDFP, LA dimension index >30mm/m2, LVEDV >200cm3, preoperative NYHA class, AF, COPD, smoking, prosthesis mismatch and MR.