[Can irreversible ventricular dysfunction be identified in patients with heart valve disease?].

Cardiologists and heart surgeons are often faced with the problem of the optimal therapeutic indication in patients with valvular heart disease presenting with severe myocardial dysfunction, as it is difficult to evaluate the degree of reversibility of a severe alteration of ventricular function in these patients. Myocardial dysfunction is often multifactorial in patients with valvular heart disease and the role of myocardial ischaemia secondary to associated coronary heart disease must not be neglected. On the other hand, the compensatory capacity of the myocardium varies from one patient to another ("constitutional" myocardial factor or related to the aetiology of the valvular heart disease?). Although the methods of investigation of myocardial function currently available are able to precisely evaluate the degree of severity of myocardial dysfunction, they are unable to accurately predict the degree of reversibility. 1. In pure mitral stenosis, severe left ventricular dysfunction is very rare; more or less rapidly, pulmonary hypertension induces slowly progressive right ventricular dysfunction which remains reversible for a long time. 2. In mitral incompetence, left ventricular systolic function is correctly evaluated by the ejection fraction (LVEF). There is a high risk of irreversible left ventricular dysfunction in operated patients with an LVEF of less than 0.40. In these patients, left ventricular function is slightly improved after mitral repair, while LVEF decreases after mitral valve replacement. The combined study of right ventricular systolic function is useful in patients with mitral disease, as this function may be insidiously altered and the presence of right heart failure, regardless of its cause, considerably increases the late postoperative mortality of mitral valve disease. 3. In aortic stenosis, left ventricular dysfunction, hypertrophy and interstitial fibrosis remain reversible for a long time. Severe alteration of LV function therefore does not exclude the possibility of very good postoperative recovery. However, this is improbable in the presence of: a very marked increase in LV mass and/or end-systolic volume, and/or inoperable associated coronary artery disease, and/or the combination of low ejection fraction, severely decreased cardiac output, and low transvalvular gradient (not increased by cautious dobutamine infusion), and/or clinical signs of complete heart failure. 4. In aortic incompetence, progressive alteration of left ventricular function, often asymptomatic, is reflected by the increased dimensions of the LV and a reduction of the fraction of ejection. The reversibility of LV dysfunction is difficult for evaluate. The long clinical course of this dysfunction is one of the most reliable predictors of irreversibility, together with a fall in the resting isotope LVEF.(ABSTRACT TRUNCATED AT 250 WORDS)