Tarantini Giuseppe, Buja Paolo, Scognamiglio Roldano, Razzolini Renato, Gerosa Gino, Isabella Giambattista, Ramondo Angelo, Iliceto Sabino
Department of Cardiology and Cardio-thoracic Surgery, Policlinico Universitario, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
Eur J Cardiothorac Surg. 2003 Dec;24(6):879-85. doi: 10.1016/s1010-7940(03)00575-x.
The influence of left ventricular (LV) dysfunction on survival of patients with severe aortic stenosis is poorly characterized. Few data are available about preoperative predictors of cardiac mortality and LV function recovery after aortic valve replacement of such patients. The aim of our study was to examine the outcome and the preoperative predictors of postoperative cardiac death and of LV function recovery in these patients.
We evaluated 85 consecutive patients with severe aortic stenosis (aortic valve area <1 cm(2)) and severe depression of LV ejection fraction (EF) <35% at cardiac catheterization. Among them, 52 underwent aortic valve replacement and they were compared to patients who were not operated on. All patients had a mean clinical follow-up of 53 months and 94% of them had a mean echocardiographic follow-up of 14 months after aortic valve replacement.
The mean baseline characteristics included: LVEF 28+/-6%, peak-to-peak transvalvular gradient 51+/-29 mmHg, aortic valve area 0.63+/-0.25 cm(2). Thirty-three patients did not undergo aortic valve replacement: 32 of them died within 3 years. Fifty-two patients underwent aortic valve replacement and 16 had a concomitant coronary bypass surgery. In-hospital mortality was 8%. Postoperative NYHA functional class changed from 2.84+/-0.67 to 1.43+/-0.44 (P<0.001) and LVEF from 29+/-6% to 43+/-10% (P<0.001). At follow-up 10 patients died of heart disease. By multivariate analysis, preoperative LV end-systolic volume index (ESVI) was the only covariate of cardiac death (LVESVI/10 ml/m(2), OR 1.3, CI 1.1-1.8, P<0.028). By using a receiver operating characteristic curve, LVESVI< or =90 ml/m(2) was the best cut-off value (sensitivity and specificity 78%) to fit with a better survival (93% vs. 63%, P<0.01) and with LVEF recovery after aortic valve replacement (EF improved by 15+/-10% vs. 8+/-5%, P<0.001).
Despite LV dysfunction, aortic valve replacement appears to change drastically the natural history of severe aortic stenosis. Preoperative LV levels predict different postoperative survival rate and LVEF recovery.
左心室（LV）功能障碍对重度主动脉瓣狭窄患者生存率的影响目前尚无明确描述。关于此类患者主动脉瓣置换术后心脏死亡的术前预测因素以及左心室功能恢复情况的数据较少。我们研究的目的是探讨这些患者术后的结局以及术后心脏死亡和左心室功能恢复的术前预测因素。
我们评估了85例连续性重度主动脉瓣狭窄（主动脉瓣面积<1 cm²）且心脏导管检查时左心室射血分数（EF）严重降低（<35%）的患者。其中，52例接受了主动脉瓣置换术，并与未接受手术的患者进行比较。所有患者平均临床随访53个月，其中94%的患者在主动脉瓣置换术后平均超声心动图随访14个月。
平均基线特征包括：左心室射血分数28±6%，跨瓣压差峰值51±29 mmHg，主动脉瓣面积0.63±0.25 cm²。33例患者未接受主动脉瓣置换术：其中32例在3年内死亡。52例患者接受了主动脉瓣置换术，16例同时进行了冠状动脉搭桥手术。住院死亡率为8%。术后纽约心脏协会（NYHA）心功能分级从2.84±0.67变为1.43±0.44（P<0.001），左心室射血分数从29±6%变为43±10%（P<0.001）。随访期间，10例患者死于心脏病。多因素分析显示术前左心室收缩末期容积指数（ESVI）是心脏死亡的唯一协变量（每10 ml/m²左心室收缩末期容积指数，比值比1.3，可信区间1.1 - 1.8，P<0.028）。通过绘制受试者工作特征曲线，左心室收缩末期容积指数≤90 ml/m²是最佳截断值（敏感性和特异性均为78%），与更好的生存率（93%对63%，P<0.01）以及主动脉瓣置换术后左心室射血分数恢复情况相符合（左心室射血分数提高15±10%对8±5%，P<0.001）。
尽管存在左心室功能障碍，但主动脉瓣置换术似乎能显著改变重度主动脉瓣狭窄的自然病程。术前左心室水平可预测不同的术后生存率和左心室射血分数恢复情况。
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