Aortic Valve Surgery and Reduced Ventricular Function

Aortic valve disease is a fatal disease with but a single cure. Removal of the mechanical obstruction in aortic stenosis (surgery or TAVI) and replacement of an incompetent valve (so far only surgery) are the only treatment options. While aortic valve replacement in patients with isolated valve disease and normal pumpfunction of the heart has become a routine procedure and is performed with excellent results all over the world, it can be a rather challenging procedure in severely ill patients with heart failure and comorbidities. Patients with low ejection fraction are one of the most challenging patient groups in cardiac surgery. According to the guidelines for the management of patients with valvular heart disease as recommended by all major heart associations including the European Society of Cardiology, American College of Cardiology, American Heart a ventricular function reduced to below 50% ejection fraction is considered a class I, level of evidence B and C indication respectively for aortic valve surgery. (ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease, Bonow et al., 2006) Despite this fact there is a high number of patients presenting with severely reduced ventricular function for aortic valve surgery. In aortic insufficiency 70% have a function reduced to below 50% and around 10% present with a significantly reduced function of less than 30% EF. In case of aortic stenosis the numbers are a less dramatic but still more than 40 % of patients referred for valve surgery have an ejection fraction below 50%. This is due to the fact that aortic valve disease can go unnoticed for a very long time resulting in heart failure at time of presentation. Another fact is that at least some patients are treated conservatively for a too long period of time until their EF deteriorates. Apart from that, due to the demographic development there is an increasing number of patients with aortic valve disease and advanced age resulting in a high number of elderly patients with more comorbidities and reduced ejection fraction.