Pathophysiology and Natural History Valvular Heart Disease

The afterload-corrected end-systolic volume index (ratio of end-systolic stress to endsystolic volume index [ESS/ESVI]) was previously useful in predicting outcome in patients with mitral regurgitation undergoing valve replacement. Therefore we tested ESS/ESVI together with standard hemodynamic variables as possible predictors of outcome in 39 patients with various valvular lesions who underwent valve replacement. Thirteen patients had preoperative mitral regurgitation, 16 had aortic stenosis, nine had aortic regurgitation, and one had mitral stenosis. Twenty-seven patients (group S) had a satisfactory outcome as defined by a return to NYHA class I or II together with a normal postoperative ejection fraction. Twelve patients who died, remained in class III or IV, or had a subnormal postoperative ejection fraction were deemed to have an unsatisfactory result (group U). Mean right atrial pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, enddiastolic volume index, end-systolic volume index (ESVI), and end-systolic wall stress were all greater in group U, whereas ESS/ESVI and ejection fraction were lower in group U. When these and other factors were submitted to stepwise discriminant multivariate analysis, ESS/ESVI and ESVI were the only independent predictors of outcome. However, when patients with mitral regurgitation (who might have biased the study) were excluded, discriminant analysis showed ESVI as the only independent predictive variable. We conclude that end-systolic indicators of ventricular function are superior to other standard hemodynamic variables in predicting outcome of valve replacement. Circulation 74, No. 6, 1309-1316, 1986 PREOPERATIVE left ventricular function is generally accepted as an important determinant of the outcome of valve replacement surgery.' Thus accurate assessment of left ventricular function is important in preoperative patient evaluation. Unfortunately, standard ejection phase indexes of left ventricular function such as ejection fraction are altered by the abnormalities in preload and afterload that usually accompany valvular heart disease. It is not surprising, therefore, that ejection phase indexes have been shown to overestimate or underestimate ventricular function in patients with valvular heart disease according to the loading abnormalities present. '5 Thus a measure of left ventricular function that is independent of or accounts for loading conditions should be superior to ejection phase indexes in predicting surgical outcome. End-systolic volume is independent of preload and varies directly and linearly From the Section of Cardiology, Department of Medicine, Temple University School of Medicine, Philadelphia. Address for correspondence: Blase A. Carabello, M.D., Department of Medicine, Division of Cardiology, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC 29425. Received May 16, 1985; revision accepted Aug. 28, 1986. Vol. 74, No. 6, December 1986 with afterload.6t0 Correcting end-systolic volume for afterload and body size could yield an index of ventricular function that would be less influenced by loading than would ejection phase indexes. We postulated that such an index would be useful in the preoperative evaluation of patients with valvular heart disease. In a previous study of patients with mitral regurgitation, end-systolic volume index corrected for wall stress (i.e., the ratio of end-systolic wall stress to end-systolic volume index [ESS/ESVI]) was superior to other preoperative hemodynamic and angiographic measurements in predicting surgical outcome.3 We wished to assess the usefulness of this index in predicting surgical outcome of valve replacement in patients with valvular heart disease whether the lesion was stenotic or regurgitant or involved the mitral or aortic valve. Therefore this study was conducted to test the ESS/ESVI as a predictor of outcome in patients with valvular heart disease. Methods Patients and experimental design. Angiograms and pressure tracings from all 74 patients who underwent single, first 1309 by gest on A ril 0, 2017 http://ciajournals.org/ D ow nladed from