Impact of recent 2021 ESC guideline changes on postoperative survival of patients with severe aortic regurgitation: insights from the AVIATOR registry

Background

Until 2021, the strongest guidelines on surgical correction of severe aortic regurgitation (AR) focused on the left ventricular systolic function (LVEF) and the presence of symptoms. However, those situations lead to an outcome penalty, even after surgical correction. Left ventricle end-systolic diameter (LVESD) gained in strength in 2021 European guidelines. Moreover, more inclusive cut-off values are now recommended (class IIb) in patients at low surgical risk, reflecting the will to recommend surgery before developing heart failure and its consequences on post-operative outcome.

Purpose

We sought to evaluate the impact of guidelines triggers and their recent changes on postoperative survival of patients with severe AR from a large multicentric international registry.

Method and results

Postoperative overall survival of 1899 patients operated for severe and chronic AR (mean age 49±15 years, 85% male) in the international multicenter surgery registry for aortic valve surgery, AVIATOR, was evaluated over a median of 37 months. Twelve patients (0.6%) died postoperatively, and 68 within 10 years. By multivariable Cox analysis, presence of heart failure symptoms (HR 2.60; 95% CI [1.20–5.66]; p=0; 016), and either LVESD >50 mm or >25 mm/m2 (HR 1.64; 95% CI [1.05–2.55]; p=0.029) predicted survival independently over and above age (HR 2.25 per SD, 95% CI [1.67–3.03], p<0.001), female gender and bicuspid phenotype. Therefore, patients operated on when meeting either old or new 2021 class I triggers had worse adjusted survival (respectively 86±2% and 87±2%) than patients operated on without meeting triggers (97±2%, p<0.01). However asymptomatic patients operated on while meeting new 2021 ESC class IIb triggers (ie LVESD >20 mm/m2 or LVEF between 50–55%, 10-year survival 97±3%). Moreover, the sub-group of patients having a dilated LVESD >50 mm or >25 mm/m2 but a preserved LVEF >50% had excellent survival (10-year survival 95±3%).

Conclusions

In severe AR, patients operated on when meeting any class I trigger have postoperative survival penalty. Asymptomatic patients operated on earlier have better survival. This supports early surgery in AR as encouraged by the recent ESC/EACTS guidelines.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fondation Nationale de la Recherche Scientifique of the Belgian Government

Quality of life after aortic valve repair is similar to Ross patients and superior to mechanical valve replacement: a cross-sectional study

Background

In patients after aortic valve surgery, the quality of life is hypothesized to be influenced by the type of the valve procedure. A cross-sectional study on the postoperative quality of life was carried out in patients after aortic valve-sparing surgery (with regards to the age of the patient), Ross procedure and mechanical aortic valve replacement.

Methods

Quality of life was studied in 139 patients after aortic valve surgery divided into four study groups (Y – aortic valve-sparing procedure at the age below 50 years, mean age 36.2 years; O – aortic valve-sparing procedure at the age 50 years and over, mean age 59.2 years; R – Ross procedure, mean age 37.8 years and M – mechanical aortic valve replacement at the age below 50 years, mean age 39.2 years). SF-36 Short Form and valve-specific questionnaires were mailed to the patients after 6 months or later following surgery (median 26.9 months).

Results

In SF-36, the younger aortic valve repair patients and the Ross patients scored significantly better in 4 of 4 physical subscales and in 2 of 4 mental subscales than the older aortic valve repair and mechanical valve replacement patients. In the valve-specific questionnaire; however, all 3 groups free of anticoagulation (Y, O, and R) displayed greater freedom from negative valve-related concerns.

Conclusions

Postoperative quality of life is influenced by the type of aortic valve procedure and is negatively linked with mechanical prosthesis implantation and long-term anticoagulation. Aortic valve-sparing strategy should be considered in cases with suitable valve morphology due to favorable clinical results and beneficial impact on the long-term quality of life.

Monitoring of the very early changes of left ventricular diastolic function in patients with acute leukemia treated with anthracyclines

AIM

To analyze the very early changes of diastolic LV function during and after chemotherapy (CT) in patients with newly diagnosed acute leukemia.

METHODS

26 patients with acute leukemia have been studied. The cardiac echo evaluation was performed at the baseline (before CT), after the first CT (mean cumulative anthracyclines dose 136.3-/+28.3 mg m(-2)), after the last CT (mean cumulative anthracyclines dose 464.3-/+117.5 mg m(-2)) and circa 6 months after the completion of CT.

RESULTS

We found a significant decrease in LVEF (65.3-/+4.5' vs 60.2-/+5.7', p<0.01), the fractional shortening of the LV (34.8-/+3.7', vs 29.5-/+5.0', p<0.01), but the mitral flow rapid filling velocity (E-wave) was not changed (0.74-/+0.18 ms(-1), vs 0.67-/+0.17 ms(-1), p ns), and atrial filling velocity (A-wave) increased (0.66-/+0.15 ms(-1) vs 0.78-/+0.18 ms(-1), p<0.01). E/A ratio significantly decreased (1.18-/+0.35 vs 0.89-/+0.27, p<0.01). IVRT increased (71.5-/+11.6 ms vs 84.0-/+11.6 ms, p<0.01). DT E-wave velocity increased (162.3-/+25.8 ms vs 206.7-/+25.5 ms, p<0.01). After the first CT, the signs of LV diastolic dysfunction were detected in 5 (19.2') patients. 6 months after the last CT, two of these patients (7.7') developed LV systolic dysfunction with the clinical symptoms of heart failure. Six months after the last CT, 12 (46.2') patients developed the signs of LV diastolic dysfunction.

CONCLUSION

Chemotherapy can induce early changes of diastolic left ventricular function. We consider using Doppler echocardiography as the election tool not only for baseline cardiologic screening but also for the monitoring of the earliest subclinical signs of cardiotoxicity.

Nebivolol in the treatment of cardiac failure: a double-blind controlled clinical trial

BACKGROUND

Nebivolol is a highly cardioselective long-acting beta-blocker with vasodilating properties, which acts in part via the endothelial L-arginine/nitric oxide pathway. As an antihypertensive drug it is effective in once-daily dosage. Nebivolol has previously been shown to improve left ventricular function in patients with cardiac impairment.

METHODS AND RESULTS

This paper reports a double-blind randomized trial comparing, in patients with heart failure, once-daily nebivolol 2.5 or 5.0 mg (initiated in all at 2.5 mg) with placebo on a constant background of digitalis plus diuretic. There was with nebivolol no overall deterioration of cardiac function or cardiac symptoms, and especially not of exercise capacity, in comparison with placebo. One patient on nebivolol 2.5 mg developed hypotension and pulmonary edema, and one patient on nebivolol 5 mg, bradycardia. All the remaining patients continued with unchanged diuretic and digitalis dosage. Nebivolol was accompanied by a trend toward clinical and functional improvement; rather better results were obtained with 2.5 than 5.0 mg.

CONCLUSIONS

In view of increasing interest in beta-blockade in heart failure, nebivolol merits further study in this context. The capacity of nebivolol to enhance endothelial nitric oxide production appears potentially attractive.

Radionuclide determined pulmonary blood volume in ischaemic heart disease

Most measurements of pulmonary blood volume have been based on the Stewart-Hamilton dye dilution principle and have required direct catheterisation of the cardiac chambers. Alternatively a precordial counter may be used to detect the composite right and left heart curves after an intravenous injection of radionuclide. We investigated the use of a gamma camera/computer system to determine the radionuclide dilution curves from individual cardiac chambers. Pulmonary transit time and pulmonary blood volume were measured in nine normal subjects, eight patients with angina pectoris but without heart failure, and 13 patients with ischaemic heart disease and left ventricular failure. Patients with heart failure had significantly greater (p less than 0.001) pulmonary blood volumes and pulmonary transit times than normal subjects or patients without heart failure. Reproducibility measurements of pulmonary blood volume, determined in 12 subjects, gave a coefficient of variation of 2.6%. The effect of posture on pulmonary blood volume was determined in six subjects lying supine and tilted at a 45 degree angle. A reduction in pulmonary blood volume in the tilted position was observed in each subject (p less than 0.005). This simple non-invasive measurement should allow more detailed assessment of physiological or pharmacological changes of the pulmonary vascular bed.

An index of valvular regurgitation from a radionuclide bolus

Mitral and aortic regurgitation was assessed from analysis of activity-time curves from right and left ventricles following the intravenous bolus injection of 99Tcm-labelled human serum albumin. The differences in the initial arrival times and the mean transit times for the ventricles were combined to provide an index of regurgitation. The mean index for 18 patients with good ventricular function and no regurgitation was -0.07 +/- 0.55 (SD) seconds. This was not significantly different from the mean value of 0.39 +/- 1.22 s obtained for 9 patients with left ventricular failure but no regurgitation. The indices for 16 patients with mitral or aortic regurgitation agreed well with the severity as assessed by contrast angiography. The mean indices for the mild, moderate and severe regurgitation groups were 2.62 +/- 1.13 s, 5.30 +/- 3.05 s and 10.15 +/- 3.62 s respectively.

Noninvasive Doppler ultrasound evaluation of aortocoronary bypass

Using ultrasound method, aortocoronary bypass patency was determined by means of bidirectional Doppler's flowmeter. In 8 (3%) of 302 subjects without aortocoronary bypass was recorded diastolic signal which might distort the results of postoperative evaluation of graft patency. Two-hundred and ninety-seven patients with 330 aortocoronary bypasses were studied at the mean time of 8 months after operation. The graft patency was 84.5%. Comparison of 89 ultrasound findings with angiographic results established considerable specificity (90%) and sufficient sensitivity (77%). Reproducibility of this method was also good. The method is inexpensive and not time consuming. The advantages are also its safety and convenience for the patient. In the present level of development it can be used mainly as screening test at long-term follow-up of aortocoronary graft patency.