title: Early Left and Right Ventricular Response to Aortic Valve Replacement.
abstract: The immediate effect of aortic valve replacement (AVR) for aortic stenosis on perioperative myocardial function is unclear. Left ventricular (LV) function may be impaired by cardioplegia-induced myocardial arrest and ischemia-reperfusion injury, especially in patients with LV hypertrophy. Alternatively, LV function may improve when afterload is reduced after AVR. The right ventricle (RV), however, experiences cardioplegic arrest without benefiting from improved loading conditions. Which of these effects on myocardial function dominate in patients undergoing AVR for aortic stenosis has not been thoroughly explored. Our primary objective is thus to characterize the effect of intraoperative events on LV function during AVR using echocardiographic measures of myocardial deformation. Second, we evaluated RV function.
  
  
  
  In this supplementary analysis of 100 patients enrolled in a clinical trial (NCT01187329), 97 patients underwent AVR for aortic stenosis. Of these patients, 95 had a standardized intraoperative transesophageal echocardiographic examination of systolic and diastolic function performed before surgical incision and repeated after chest closure. Echocardiographic images were analyzed off-line for global longitudinal myocardial strain and strain rate using 2D speckle-tracking echocardiography. Myocardial deformation assessed at the beginning of surgery was compared with the end of surgery using paired t tests corrected for multiple comparisons.
  
  
  
  LV volumes and arterial blood pressure decreased, and heart rate increased at the end of surgery. Echocardiographic images were acceptable for analysis in 72 patients for LV strain, 67 for LV strain rate, and 54 for RV strain and strain rate. In 72 patients with LV strain images, 9 patients required epinephrine, 22 required norepinephrine, and 2 required both at the end of surgery. LV strain did not change at the end of surgery compared with the beginning of surgery (difference: 0.7 [97.6% confidence interval, -0.2 to 1.5]%; P = 0.07), whereas LV systolic strain rate improved (became more negative) (-0.3 [-0.4 to -0.2] s; P < 0.001). In contrast, RV systolic strain worsened (became less negative) at the end of surgery (difference: 4.6 [3.1 to 6.0]%; P < 0.001) although RV systolic strain rate was unchanged (0.0 [97.6% confidence interval, -0.1 to 0.1]; P = 0.83).
  
  
  
  LV function improved after replacement of a stenotic aortic valve demonstrated by improved longitudinal strain rate. In contrast, RV function, assessed by longitudinal strain, was reduced.
authors.affiliation: From the Departments of *Cardiothoracic Anesthesia and †Outcomes Research, Cleveland Clinic, Cleveland, Ohio; ‡Anesthesia Institute, §Department of Cardiothoracic Anesthesia, ‖Department of Quantitative Health Sciences, ¶Department of Cardiovascular Medicine, and #Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Andra E
authors.initials: AE
authors.lastname: Duncan
authors.forename: Sheryar
authors.initials: S
authors.lastname: Sarwar
authors.forename: Babak
authors.initials: B
authors.lastname: Kateby Kashy
authors.forename: Abraham
authors.initials: A
authors.lastname: Sonny
authors.forename: Shiva
authors.initials: S
authors.lastname: Sale
authors.forename: Andrej
authors.initials: A
authors.lastname: Alfirevic
authors.forename: Dongsheng
authors.initials: D
authors.lastname: Yang
authors.forename: James D
authors.initials: JD
authors.lastname: Thomas
authors.forename: Marc
authors.initials: M
authors.lastname: Gillinov
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000601:surgery; D062186:Arterial Pressure; D001026:Coronary Artery Bypass; D017548:Echocardiography, Transesophageal; D004837:Epinephrine / Q000627:therapeutic use; D005260:Female; D019918:Heart Valve Prosthesis Implantation; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D009638:Norepinephrine / Q000627:therapeutic use; D014662:Vasoconstrictor Agents / Q000627:therapeutic use; D016277:Ventricular Function, Left; D016278:Ventricular Function, Right
chemical_list: D014662:Vasoconstrictor Agents; D009638:Norepinephrine; D004837:Epinephrine