title: Aortic valve replacement: a safe and durable option in patients with impaired left ventricular systolic function.
abstract: BACKGROUND
  The natural history of aortic valve disease associated with ventricular dysfunction is dismal. Aortic valve replacement (AVR) is associated with increased mortality in patients with left ventricular dysfunction and the long-term outcome in these patients is not well-known. We evaluated perioperative outcomes and long-term results in patients with impaired left ventricular systolic function undergoing AVR.
  
  
  METHODS
  Retrospective analysis identified 132 consecutive patients with a left ventricular ejection fraction (LVEF)<40% who underwent AVR with or without concomitant coronary artery bypass grafting (CABG) between 1990 and 2003. Patients with other valve pathology were excluded.
  
  
  RESULTS
  Ages ranged from 29 to 94 years (mean 63+/-12), and 117 patients (89%) were male. Preoperatively, 82% were in NYHA III-IV. Sixty patients (45%) underwent AVR for severe aortic stenosis (AS) whilst 72 (55%) had aortic insufficiency (AI). In the AS group, the mean LVEF and aortic valve area were 26+/-4% and 0.8+/-0.4 cm(2), respectively. AI patients had a mean LVEF of 27+/-6% and a mean left ventricular end systolic diameter of 52+/-9 mm. Fifty-seven (43%) required concomitant CABG. There were only three perioperative deaths (2.3%) and no strokes. One patient (0.8%) had postoperative renal failure, and one suffered a myocardial infarct. Nine patients (6.9%) required a postoperative IABP. LVEF increased to 29+/-10% and 34+/-12% after six months in the AS and AI groups, respectively. The mean follow-up period was 6.1 years and no differences between the AS and AI groups were observed with respect to either perioperative or long-term outcomes. Overall survival was 96%, 79% and 55% at 1, 5 and 10 years, respectively.
  
  
  CONCLUSIONS
  The long asymptomatic course of AS and AI means that many patients have impaired ventricular function at diagnosis. This study demonstrates that AVR in such patients can be performed with low perioperative morbidity and mortality. The outlook after surgery is excellent. A 10-year-survival of 55% compares favourably with heart transplantation and particularly with medical therapy. AVR is a safe, effective and durable option, which should not be denied to patients on the basis of low LVEF alone.
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada. andrew.sara@btinternet.com
authors.forename: Andrew
authors.initials: A
authors.lastname: Chukwuemeka
authors.forename: Vivek
authors.initials: V
authors.lastname: Rao
authors.forename: Susan
authors.initials: S
authors.lastname: Armstrong
authors.forename: Joan
authors.initials: J
authors.lastname: Ivanov
authors.forename: Tirone
authors.initials: T
authors.lastname: David
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000150:complications / Q000601:surgery; D001024:Aortic Valve Stenosis / Q000150:complications / Q000601:surgery; D001026:Coronary Artery Bypass; D005260:Female; D005500:Follow-Up Studies; D006349:Heart Valve Diseases / Q000150:complications / Q000401:mortality / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D015996:Survival Rate; D013599:Systole; D018487:Ventricular Dysfunction, Left / Q000150:complications / Q000401:mortality / Q000601:surgery*