Exercise radionuclide ventriculography for predicting post-operative left ventricular function in chronic aortic regurgitation.
OBJECTIVE
Ejection fraction (EF) reaction upon exercise by radionuclide ventriculography and standard echocardiographic parameters was evaluated as predictors for post-operative left ventricular (LV) function in chronic aortic regurgitation (AR).


BACKGROUND
The optimal timing of surgery for chronic AR is when the left ventricle is still compensating for the volume and pressure overload without irreversible dysfunction. For asymptomatic patients when EF is normal and LV diameters are borderline, exercise testing is recommended by present guidelines. However, only a limited number of studies have been performed, and data are scarce on this subject.


METHODS
Radionuclide ventriculography with multiple gated acquisition at rest and during exercise was performed in 29 consecutive patients with severe chronic aortic regurgitation pre-operatively and 6 months post-operatively. Patient subgroups were formed based on pre-operative EF exercise response (DeltaEF) and were categorized as decreasing (DeltaEF <-5%), unaltered (-5% <or= DeltaEF <or= 5%), and increasing (DeltaEF > 5%). A 5% or higher increase was considered normal. The LV diameters and mass were measured by echocardiography.


RESULTS
Pre-operative LV diameters were markedly elevated before surgery and diminished significantly after surgery. Left ventricular diameters, LV mass, EF at rest (EF(rest)), and EF change from rest to exercise (DeltaEF) were independent of New York Heart Association functional class. Pre-operative end-diastolic diameter proved to be a predictor for pre- and post-operative DeltaEF (p = 0.003; p = 0.04) but not for the nature of the exercise response post-operatively. Patients with decreasing and unaltered EF pre-operatively presented a significantly higher but still abnormal DeltaEF post-operatively. Those with increasing EF pre-operatively had a similar response and a normal DeltaEF post-operatively. Pre-operative DeltaEF was not only a predictor for post-operative DeltaEF (p = 0.02) but also classified patients into post-operative subgroups (EF decreasing, p = 0.03; unaltered, p = 0.02; increasing, p = 0.0008).


CONCLUSIONS
An abnormal EF response to exercise may also occur in patients who do not fulfill criteria for surgery based on LV dimensions or EF. A follow-up of exercise LV function and adjusting the timing of surgery according to the nature of exercise response could, therefore, be beneficial.
Department of Cardiothoracic Surgery, Heart Centre in Ostergötland, University Hospital Linköping, Linköping, Sweden. eva.tamas@liu.se
Eva
E
Tamás
Mats
M
Broqvist
Eva
E
Olsson
Stefan
S
Franzén
Eva
E
Nylander
D000368:Aged; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D006348:Cardiac Surgical Procedures / Q000009:adverse effects; D002908:Chronic Disease; D018450:Disease Progression; D025401:Echocardiography, Stress; D005080:Exercise Test; D005260:Female; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011237:Predictive Value of Tests; D015635:Radionuclide Ventriculography; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D016277:Ventricular Function, Left