Survival after Aortic Valve Replacement for Aortic Regurgitation: Prediction from Preoperative Contractility Measurement

Background: Noninvasive measurement of myocardial contractility (end-systolic wall stress-adjusted change in left ventricular ejection fraction from rest to exercise [Delta LVEF - Delta ESS]) predicts heart failure, subnormal LVEFrest, and sudden death in asymptomatic patients with chronic severe aortic regurgitation (AR). Here we assess the relation of preoperative Delta LVEF - Delta ESS to survival after aortic valve replacement (AVR). Methods: Patients who underwent AVR for chronic, isolated, pure severe AR (n = 66) were followed for 13.0 +/- 6.4 event-free years. Preoperative Delta LVEF - Delta ESS (from combined echocardiographic and radionuclide cineangiographic data) enabled cohort stratification into 3 terciles (-1 to -11% [normal or mild] contractility deficit, -12 to -16% [moderate], and -17% [severe], identical with segregation in our earlier study) to relate preoperative contractility to postoperative survival and to age- and gender-matched US census data. Results: Since AVR, 22 patients died (average annual risk [AAR] for all-cause mortality for the entire co hort = 3.15%). Preoperative Delta LVEF - Delta ESS predicted postoperative survival (p = 0.009, log rank test). By contractility terciles, all-cause AARs were 1.44, 2.58, and 6.40%. Survival was lower than among US census comparators (p < 0.02), but the mild tercile was indistinguishable from census data (p = ns). By multivariable Cox regression, survival prediction by pre-AVR Delta LVEF - Delta ESS was independent of, and superior to, prediction by age at surgery, gender, preoperative functional class, LVEFrest, LVEFexercise, change in LVEFrest to exercise, and LV diastolic or systolic dimensions (p <= 0.01, pre-AVR Delta LVEF - Delta ESS vs. other covariates). Conclusion: In severe AR, preoperative contractility predicts post-AVR survival and may be prognostically superior to clinical, geometric and performance descriptors, potentially impacting on patient selection for surgery. (C) 2018 The Author(s) Published by S. Karger AG, Basel