Ventricular energetics in aortic root replacement for annuloaortic ectasia with aortic regurgitation

Influence of Bentall Procedure on Left Ventricular Function

Objective

To evaluate the influence of Bentall procedure on left ventricular function and condition on long-term follow-up.

Methods

Seventy-three consecutive patients who underwent an aortic root and ascending aorta replacement with composite valve button Bentall or flanged Bentall technique, from January 2007 to November 2018, were included in this retrospective study.

Results

Postoperative left ventricular ejection fraction significantly increased (52.14±11.38 vs. 56.79±11.36; P=0.041), left ventricular end-systolic diameter significantly reduced (38.25±9.31 mm vs. 34.17±9.15 mm; P=0.027), left ventricular end-diastolic diameter significantly reduced (56.42±9.72 mm vs. 51.58±9.03 mm; P=0.01), and left atrial diameter significantly reduced (45.33±12.77 mm vs. 39.25±12.41 mm; P=0.01), compared to preoperative values. Our long-term survival results are comparable with previous studies in which survival rates in 5 years and 10 years were 83.5% and 69.8%, respectively. In comparing patients according to their New York Heart Association (NYHA) functional class, it was shown that their postoperative functional capacity was improved during the follow-up period (2.1±0.56 vs. 1.2±0.42; P=0.001).

Conclusion

The Bentall procedure significantly improved the left ventricular systolic function and condition and decreased the left ventricular end-systolic and end-diastolic diameters and the left atrial diameter on long-term follow-up, based on the transthoracic echocardiography. Bentall procedure can be performed with acceptable mortality and morbidity rates on long-term follow-up.

Aortic root ectasia as a phenotypic feature of a mitochondrial disorder

Mitochondrial disorder (MID) can be suspected upon application of the mitochondrial multiorgan disorder syndrome score; aortic root ectasia (ARE) can be a phenotypic feature of MIDs; ARE in a MID may result from affection of vascular smooth muscle cells by the metabolic defect; ARE requires long-term follow-up not to miss the point at which ARE transforms to an aneurysm requiring vascular surgery.

Effect of Elective Bentall Procedure on Left Ventricular Systolic Function and Functional Status: Long-Term Follow-Up in 90 patients

Because there are so few data on the long-term effects on left ventricular systolic function and functional status in patients who electively undergo Bentall procedures, we established a retrospective study group of 90 consecutive patients. This group consisted of 71 male and 19 female patients (mean age, 54 ± 10 yr) who had undergone the Bentall procedure to correct aortic valve disease and aneurysm of the ascending aorta, from 1997 through 2003 in a single tertiary-care center. We monitored these patients for a mean period of 117 ± 41 months for death, left ventricular ejection fraction and volume indices, and functional capacity as determined by New York Heart Association (NYHA) class. There were no operative deaths. The survival rate was 73.3% during follow-up. There were 10 cardiac and 13 noncardiac deaths, and 1 death of unknown cause. Echocardiography was performed before the index procedure and again after 117 ± 41 months. In surviving patients, statistically significant improvement in left ventricular ejection fraction, in comparison with preoperative values (0.49 ± 0.11 vs 0.41 ± 0.11; P <0.0001), was noted at follow-up. Similarly, we observed statistically significant reductions in left ventricular end-systolic (39.24 ± 28.7 vs 48.77 ± 28.62 mL/m(2)) and end-diastolic volumes (54.63 ± 6.97 vs 59.17 ± 8.92 mL/m(2); both P <0.0001). Most patients (53/66 [80.3%]) progressed from a higher to a lower NYHA class during the follow-up period. The Bentall procedure significantly improved long-term left ventricular systolic function and functional status in surviving patients who underwent operation on a nonemergency basis.

Cardiac energetics analysis after aortic valve replacement with 16-mm ATS mechanical valve

The 16-mm ATS mechanical valve is one of the smallest prosthetic valves used for aortic valve replacement (AVR) in patients with a very small aortic annulus, and its clinical outcomes are reportedly satisfactory. Here, we analyzed the left ventricular (LV) performance after AVR with the 16-mm ATS mechanical valve, based on the concept of cardiac energetics analysis. Eleven patients who underwent AVR with the 16-mm ATS mechanical valve were enrolled in this study. All underwent echocardiographic examination at three time points: before AVR, approximately 1 month after AVR, and approximately 1 year after AVR. LV contractility (end-systolic elastance [Ees]), afterload (effective arterial elastance [Ea]), and efficiency (ventriculoarterial coupling [Ea/Ees] and the stroke work to pressure-volume area ratio [SW/PVA]) were noninvasively measured by echocardiographic data and blood pressure measurement. Ees transiently decreased after AVR and then recovered to the pre-AVR level at the one-year follow-up. Ea significantly decreased in a stepwise manner. Consequently, Ea/Ees and SW/PVA were also significantly improved at the one-year follow-up compared with those before AVR. The midterm LV performance after AVR with the 16-mm ATS mechanical valve was satisfactory. AVR with the 16-mm ATS mechanical valve is validated as an effective treatment for patients with a very small aortic annulus. The cardiac energetics variables, coupling with the conventional hemodynamic variables, can contribute to a better understanding of the patients' clinical conditions, and those may serve as promising indices of the cardiac function.

Early mitral valve surgery for chronic severe mitral regurgitation optimizes left ventricular performance and left ventricular mass regression

OBJECTIVE

The optimal timing of mitral valve surgery for severe mitral regurgitation is controversial. We aimed to evaluate the changes in left ventricular performance using ventricular energetics and left ventricular mass regression after the surgery to determine the appropriate surgical timing in asymptomatic patients with severe mitral regurgitation.

METHODS

Fifty consecutive asymptomatic or minimally symptomatic patients who electively underwent the surgery for severe mitral regurgitation were studied retrospectively. Contractility (end-systolic elastance), afterload (effective arterial elastance), and efficiency (ventriculoarterial coupling and ratio of stroke work to pressure-volume area), and left ventricular mass index were measured echocardiographically before and 1 month after surgery. Two-way repeated-measures analysis of variance was used to compare the parameters between patients with (n = 17) and without (n = 33) left ventricular dysfunction (ie, ejection fraction ≤60% and/or end-systolic dimension ≥40 mm).

RESULTS

Contractility did not change significantly (P = .94) but the afterload increased significantly (P < .0001) in both groups. Consequently, the efficiency deteriorated significantly (ventriculoarterial coupling, P = .0004; ratio of stroke work to pressure-volume area, P < .0001). Furthermore, the left ventricular mass index improved remarkably in both groups (P < .0001). Alternatively, the patients with normal left ventricular function had greater contractility (P < .0001), less worsened efficiency (P < .0001 and P < .0001, respectively), and a better left ventricular mass index (P = .0002) after surgery.

CONCLUSIONS

Early surgery for severe mitral regurgitation preserves left ventricular performance and improves left ventricular mass regression in asymptomatic patients with normal ventricular function.