Sutton M, Plappert T, Spiegel A, Raichlen J, Douglas P, Reichek N, Edmunds L
Circulation. 1987 Jul;76(1):77-89. doi: 10.1161/01.cir.76.1.77.
We prospectively studied 16 patients with isolated aortic stenosis and eight with isolated aortic regurgitation undergoing aortic valve replacement, using two-dimensional echocardiography preoperatively, intraoperatively, and 41 +/- 7 days postoperatively to calculate the intraoperative change in afterload, quantify the postoperative changes in left ventricular chamber size, architecture, load and function, determine whether the postoperative left ventricular remodeling correlated with the intraoperative change in afterload in aortic stenosis and aortic regurgitation, and assess whether preoperative afterload excess precluded postoperative improvement in left ventricular function. Preoperative left ventricular mass, end-systolic meridional and circumferential wall stresses, ejection fraction, and stress-shortening relations in patients with aortic stenosis and aortic regurgitation were similar. However, our patients with aortic regurgitation had severe systolic dysfunction, with ejection fraction less than 55% in all but one patient, compared with only 10 of 16 patients with aortic stenosis. Left ventricular end-diastolic volume, mass/volume ratio, and chamber shape were significantly different in patients with aortic stenosis and aortic regurgitation (174 +/- 64 vs 294 +/- 140 ml, p less than .01; 1.81 +/- 0.63 vs 1.14 +/- 0.18, p less than .01; and 0.59 +/- 0.09 vs 0.69 +/- 0.09, p less than .05, respectively). Intraoperative end-systolic meridional and circumferential stresses fell significantly in patients with aortic stenosis but remained unchanged in those with aortic regurgitation. The changes in left ventricular volume and ejection fraction during early postoperative remodeling (6 weeks) correlated with the intraoperative change in afterload in patients with aortic stenosis. In contrast, there was no intraoperative change in afterload in patients with aortic regurgitation and no significant changes in left ventricular volume, architecture, or function at 6 weeks or at 6 months. The differences in left ventricular remodeling and changes in function between patients with aortic stenosis and aortic regurgitation in the early postoperative period most probably relates to the major difference in intraoperative reduction in afterload, although a contributory role may have been played by the preoperative left ventricular dysfunction in those with aortic regurgitation that was underestimated by measurement of ejection fraction.
我们前瞻性地研究了16例接受主动脉瓣置换术的单纯主动脉瓣狭窄患者和8例单纯主动脉瓣关闭不全患者，在术前、术中及术后41±7天使用二维超声心动图，以计算术中后负荷的变化，量化术后左心室腔大小、结构、负荷和功能的变化，确定主动脉瓣狭窄和主动脉瓣关闭不全患者术后左心室重构是否与术中后负荷变化相关，并评估术前后负荷过高是否会妨碍术后左心室功能的改善。主动脉瓣狭窄和主动脉瓣关闭不全患者术前的左心室质量、收缩末期经向和圆周壁应力、射血分数以及应力缩短关系相似。然而，我们的主动脉瓣关闭不全患者存在严重的收缩功能障碍，除1例患者外，所有患者的射血分数均低于55%，而主动脉瓣狭窄患者中只有10例如此。主动脉瓣狭窄和主动脉瓣关闭不全患者的左心室舒张末期容积、质量/容积比和腔室形状存在显著差异（分别为174±64 vs 294±140 ml，p<0.01；1.81±0.63 vs 1.14±0.18，p<0.01；以及0.59±0.09 vs 0.69±0.09，p<0.05）。主动脉瓣狭窄患者术中收缩末期经向和圆周应力显著下降，而主动脉瓣关闭不全患者则保持不变。主动脉瓣狭窄患者术后早期重塑（6周）期间左心室容积和射血分数的变化与术中后负荷变化相关。相比之下，主动脉瓣关闭不全患者术中后负荷无变化，术后6周或6个月时左心室容积、结构或功能也无显著变化。主动脉瓣狭窄和主动脉瓣关闭不全患者术后早期左心室重塑和功能变化的差异很可能与术中后负荷降低的主要差异有关，尽管主动脉瓣关闭不全患者术前左心室功能障碍可能起了一定作用，而射血分数测量低估了这种功能障碍。
