title: Left ventricular dynamics after aortic valve replacement: a long-term, combined radionuclide angiographic and ultrasonographic study.
abstract: Between January 1985 and July 1990, we studied 71 patients at our institution who underwent aortic valve replacement for either aortic valve regurgitation (40 patients) or stenosis (31 patients). The following prostheses were implanted: 25 St. Jude Medical valves (bileaflet), 16 Björk-Shiley (monoleaflet, tilting disc, 60 degrees convexo-concave), 16 Medtronic-Hall (monoleaflet, tilting disc), and 14 Starr-Edwards (caged ball). The patients were evaluated pre-and postoperatively by means of gated blood-pool scintigraphy and Doppler echocardiography. Postoperatively, each patient was studied at 6 months, 1 year, and then annually. The evaluations focused upon 1) scintigraphically assessed left ventricular performance indicators (end-diastolic and end-systolic volume, as well as resting and exercise ejection fraction) and 2) Doppler-derived hemodynamic indexes (peak and mean transvalvular pressure gradient, effective orifice area, regurgitant flow, and systolic wall stress). Early after aortic valve replacement, 55 (77.5%) of the patients had substantial symptomatic relief, with normal hemodynamic values both at rest and during exercise (New York Heart Association functional class I or II); another 6 patients (8.5%) maintained their preoperative status in those classes. Within a year after surgery, a majority of patients showed a significant reduction in left ventricular dimensions. The patients with preoperative aortic valve stenosis had a significantly reduced end-diastolic and end-systolic volume (p<0.05), a moderately reduced left ventricular mass index (p<0.01), and a significantly increased exercise ejection fraction (p<0.05); moreover, in all 31 of these cases, systolic wall stress returned to normal or lower-than-control values (p<0.005). The patients with preoperative aortic valve regurgitation had a significant reduction in end-diastolic and end-systolic volume (p<0.005), diastolic wall stress (p<0.005), and a significant increase in exercise ejection fraction (p<0.01); however, their left ventricular mass index was not significantly reduced. Optimal long-term survival was afforded by the St. Jude valve in the small size (21 mm) and the Starr-Edwards valve in the large size (27 mm). This study represents the first reported use of a serial, combined radionuclide and echocardiographic procedure for the follow-up of patients undergoing aortic valve replacement. During the 5(1/2)-year follow-up period, this combined technique proved highly accurate for collecting follow-up data, often complementing or correcting simple ultrasound results. This diagnostic approach enabled us to 1) obtain information comparable to or better than that provided by cardiac catheterization, 2) identify complications early, 3) differentiate between valvular and ventricular failure, and 4) suggest the valve of choice (not always that with the best hemodynamic performance) in patients with different cardiac variables. Further research is needed to confirm this study, the results of which could change many medical and surgical strategies for clinical management of the diseased aortic valve.
authors.affiliation: The Division of Cardiovascular Surgery, Department of Surgery, University of Bologna School of Medicine, Bologna, Italy.
authors.forename: C S
authors.initials: CS
authors.lastname: Masotti
authors.forename: P
authors.initials: P
authors.lastname: Bonfranceschi
authors.forename: G
authors.initials: G
authors.lastname: Rusticali
authors.forename: F
authors.initials: F
authors.lastname: Rusticali
authors.forename: A
authors.initials: A
authors.lastname: Pierangeli