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Diastolic dysfunction is one of the determinants of functional capacity in patients with severe mitral regurgitation and normal ejection fraction
Heart,
Lung
and Circulation
2000; 9
48th Annual
DIASTOLIC DYSFUNCTION IS ONE OF THE DETERMINANTS OF FUNCTIONAL CAPACITY IN PATIENTS WITH SEVERE MITRAL BEGUBGITATION AND NORMAL EJECTION FRACTION
e. M. &zr. M.J.
The Cleveland
Clinic Foundation.
J.D. w. Cleveland,
Klein, OH, USA.
Transmitral early diastolic filling (E wave) deceleration time (DT) is an important determinant of prognosis in heart failure, but has been poorly studied in mitral regurgitation (MR). We sought to ascertain whether diastolic dysfunction is a determinant of functional capacity (FC) in patients with significant chronic MR and normal lef? ventricular (LV) We identified 56 patients from our exercise function. Methods: echocardiography database over 24 months, with significant (Z 3+) MR and normal LV systolic function (ejection fraction >50%). Clinical and echocardiography variables were analysed for each patient in relation to then estimated FC in MET’s, which was adjusted for age and gender. Results: Functional capacity was poor, average or good m 22, 14 and 20 patients respectively. The key variables analysed are summarized below. Other clinical and echocardiography variables analysed, were not Objectives:
systolic pressure (mm&)
*
TISSUE DOPPLER OFFERS A QUANTITATIVE APPROACH TO DOBUTAMINE STRESS ECHO INTERPRETATION AN ANGIOGBAPHIC VALIDATION. P Cain*. L Short. J Dart D Spicer. P Garrahv. T Marwick, Princess Alexandra Hosuital. Universltv of Queensland. Brisbane. Australia.
Ba&gr&nd: V&al wall motion’ analysis &MS) of stress echocardiography requires prolonged traininp and lacks inter-observer concordance. An objective parameter of myocardial performance msy overcome these limitations. Systolic myocardial Doppler velocity (MDV) may be a sensitive quantitative index of ischemia during dobutamine echo (WE). We sought to defme normal ranges of MDV and their assess diagnostic accuracy for coronary artery disease during DbE.
Methods: We studied 242 patients undergoing DbE; 128 patients with normal wall motion; 57 at low pretest risk (normalcy group), and 114 patients with coronary angiography. Dig&d tissue Doppler images optimized for MDV (1000 Hz) were acquired in 3 apical views (GE-Vingmed System Five) during WE. MDV were analyzed offline, and normal ranges (NR, derived from the normalcy group) were used to defme segts as normal or abnormal. Wall motion (WM) analysis was assessed independently by an experienced observer. Significant CAD was defmed by >50% stenosis by quantitative angiography. In&+observer concordance and inter-observer concordance between 2 readers of MDV were measured using Cronbach’s alpha test. Accuracy of NR were defined by presence of any abnormality within a study against presence of any CAD. A similar approach was used for analysis by vascular territory. Accuracy of WMS and MDV according to presence of single or multivessel disease and image quality were also analysed. Results: NR of MDV varied according to location (basal vs midwall, septal vs free wall). Cutoffs were designated to give a specificity of 80%. Interobserver concordance was 0.81 (alpha) and in&+observer concordance was 0.87 (alpha). MDV accurately predicted significant coronary artery disease and approached the diagnostic accuracy of expert wall motion analysis; LAD LCX RCA ANY CAD WMS 71% 71% 70% 86% MDV 77% 68% 66% 80% p value p=NS p=NS p=NS p=NS Accuracy of MDV, but not WMS (p=NS) was affected by good vs. poor image
quality (82% vs. 73%, p=.OOl) and multi vs. single vessel disease (92% vs 72%, p=O.O2). Conclusions: MDV is a reproducible and quantitative measure of regional function which accurately predicts significant CAD during DbE. However, MDV remains dependent on image quality.
Meeting
of CSANZ
Al25
LONG TERM SURVIVAL AFTER AORTIC VALVE REPLACEMENT IN PATIENTS WITH LOW GRADIENT SEVERE AORTIC STENOSIS AND SEVERE LEFT VENTRICULAR SYSTOLIC DYSFUNCTION * J.J.as. Y huer. J B. Youne. I. Afiidl. The Cleveland Clinic Foundation, Cleveland, Ohio, USA. Objectives: The benefit of aortic valve replacement (AVR) for patients with severe aortic stenosis (AS) and low tiansvalvular gradients in the presence of severe left ventricular (LV) systolic dysfunction remains uncertam. previous reports of AVR m this lngh-risk group show Ixgh short and long-term mortality. We Identified 64 consecutne patients who underwent AVR Methods: between 1990 to 1998 with aortic valve area (AVA) 5 0.75 cm’, mean gradient 5 30mmHg and left ventricular ejection fraction (LVEF) < 35%. Climcal, echocardiograpic, cardiac catheterizabon and surgxal variables were analysed and patients followed for a mean of 2.8 f 2.3years. Results: There were 53 males/l I females, age = 70 + 9 years, 53% with prior myocardial infarction and 31% with prior coronary artery bypass surgery (CABG). Echocardiographic factors included: LVEF = 22 * 6%, AVA=0.62 & O.llcm*, and peak/mean gradients of 43 + 8 and 25 + 8 mmHg, respectively. Severe coronary artery disease (2 2 vessel &ease or left main) occurred in 66% and CABG was performed in 61% of patients. In-hospital mortality was 4.8%. By Kaplan-Meier analysis, l-year survival was 84% and 5-year survival was 64%. Long-term univariate predictors of mortality were age, relative
“Tricuspid regurgitation was detected in only 22 patients. Con&ions: 7) Diastolic, as well as systolii function, gender and pulmonary hypertension are determinants of FC. 2) Severity of MR is not a determinant of FC. Prospective studies are needed to better assess the significance of diastohc dysfunction in MR patients.
Scientific
risk
(RR)
=1.07
(95%
CI
=
1.01-1.14,
p=O.O3),
insulin
dependent diabetes mellitus RR=3.1 (95% CI = 1.01-9.79, p=O.O48) and right ventricular dysfunction RR=3.0 (95% CI=1.2-7.5, p=O.O2). Clinical followup was avadable in 43 of 45 long-term sm-v,vors. Mean NYHA functional class improved from 2.9 to 1.6 (p
AVR for patients with severe low transvalvular
gradient AS and
severe LV systolic dysfunction can be performed with acceptable in-hospital mortahty, favourable 1 and 5-year survival and a significant improvement in NYHA functional class.
TWENTY-EIGHT YEARS FOLLOW-UP OF PRIMARY AORTIC VALVE REPLACEMENT WITH ALLOGRAFTS - AN ECHOCABDIOGRAPHIC STUDY OF 613 PATIENTS. P. P&a. S. Burstow. M. O’Brien*. Departments of Echocardiography and Cardiac Surgery,
The Prince Charles Hospital, Brisbane, Qld. Since 1960s when aortic &grafts
(AA) have been introduced, !t has been
apparent that thx kind of aortic valve surgery offers many advantages over the prosthetic valves. The main concern regarding the AA is its durability. A”” of this study was to assess the contribuhng factors for long time uneventful longewty of AA and to defme potential failure factors 1” this group of patrents during the 28.
year follow-up. AA m@ntation was performed by a subcoronary techmque or a total mot replacement in a group of 1022 pts. (mean age 48 k 17 years, 669 male). l-he AA were cryopreserved (“=898) or “onvmble (“=124). Results: 30.day monality for the entire group was 3.0% (the last consecutive 352 pts all having root rdacement was 1.1%). Crude suw~val was 65% at >25 vears follow-uo. The re-op.&&on rate was 11.2% (n=l35) at a mean tune post surgery of 9.4 f 5.8 years. To assess the performance of AA, echocardiographic studies were nerfonned between 1996.1998 ,a 613 eatients (between 89 davs to 25 ,“ears .~oost
AA ““plantation, mean 6.7 years). Durmg that period, in 487 (59%) patxnts there
were no echocardiographic signs of either AA stenosis (AAS) or regurgdation (AAR). 42 patients (7%) had AAS and 81 (13%) AAR. There was no differences between AAS, AAR and normal AA in several valve- and procedure-related
detetinants (see Table). However, AA patients who died or had aortic valve re operation had larger aortic annulus size (recipients to donor difference) as compared to patienti with normal AA derived by echocardiogram (3.4 * 2.2 cm vs. i.3 i 2.2 Em, Pco.oot). AAS (n=42) AAR (n=8 1) Normal AA (n=490) Non-viable A&c Valve 0 3(4%) 6(1%) Clyopreserved Aorhc Valve 42(100%) 78(96%) 484(99%) Procurement time @IS) 14.3 k 8.1 14.8f7.5 15.2 + 8.5 Patients age (yrs) 41 I19 50+1t5 41+16 Age recipientidonor 14k23 20+23 15t21 Difference (yrs) I I I Aonic annulus 2.3 f 1.6 2.7 f 2.5 2.3 f2.3 Recipients/donor difference (cm) Conelusions: AA reolacement eives good lone term results at follow-uo. of UD 1 to 28 years. There was’s trend for-AAR”patxn&;nd those who ched or needed reoperation to be older and have blgger annulus diameter. No other specific patient
Lung
and Circulation
2000; 9
48th Annual
DIASTOLIC DYSFUNCTION IS ONE OF THE DETERMINANTS OF FUNCTIONAL CAPACITY IN PATIENTS WITH SEVERE MITRAL BEGUBGITATION AND NORMAL EJECTION FRACTION
e. M. &zr. M.J.
The Cleveland
Clinic Foundation.
J.D. w. Cleveland,
Klein, OH, USA.
Transmitral early diastolic filling (E wave) deceleration time (DT) is an important determinant of prognosis in heart failure, but has been poorly studied in mitral regurgitation (MR). We sought to ascertain whether diastolic dysfunction is a determinant of functional capacity (FC) in patients with significant chronic MR and normal lef? ventricular (LV) We identified 56 patients from our exercise function. Methods: echocardiography database over 24 months, with significant (Z 3+) MR and normal LV systolic function (ejection fraction >50%). Clinical and echocardiography variables were analysed for each patient in relation to then estimated FC in MET’s, which was adjusted for age and gender. Results: Functional capacity was poor, average or good m 22, 14 and 20 patients respectively. The key variables analysed are summarized below. Other clinical and echocardiography variables analysed, were not Objectives:
systolic pressure (mm&)
*
TISSUE DOPPLER OFFERS A QUANTITATIVE APPROACH TO DOBUTAMINE STRESS ECHO INTERPRETATION AN ANGIOGBAPHIC VALIDATION. P Cain*. L Short. J Dart D Spicer. P Garrahv. T Marwick, Princess Alexandra Hosuital. Universltv of Queensland. Brisbane. Australia.
Ba&gr&nd: V&al wall motion’ analysis &MS) of stress echocardiography requires prolonged traininp and lacks inter-observer concordance. An objective parameter of myocardial performance msy overcome these limitations. Systolic myocardial Doppler velocity (MDV) may be a sensitive quantitative index of ischemia during dobutamine echo (WE). We sought to defme normal ranges of MDV and their assess diagnostic accuracy for coronary artery disease during DbE.
Methods: We studied 242 patients undergoing DbE; 128 patients with normal wall motion; 57 at low pretest risk (normalcy group), and 114 patients with coronary angiography. Dig&d tissue Doppler images optimized for MDV (1000 Hz) were acquired in 3 apical views (GE-Vingmed System Five) during WE. MDV were analyzed offline, and normal ranges (NR, derived from the normalcy group) were used to defme segts as normal or abnormal. Wall motion (WM) analysis was assessed independently by an experienced observer. Significant CAD was defmed by >50% stenosis by quantitative angiography. In&+observer concordance and inter-observer concordance between 2 readers of MDV were measured using Cronbach’s alpha test. Accuracy of NR were defined by presence of any abnormality within a study against presence of any CAD. A similar approach was used for analysis by vascular territory. Accuracy of WMS and MDV according to presence of single or multivessel disease and image quality were also analysed. Results: NR of MDV varied according to location (basal vs midwall, septal vs free wall). Cutoffs were designated to give a specificity of 80%. Interobserver concordance was 0.81 (alpha) and in&+observer concordance was 0.87 (alpha). MDV accurately predicted significant coronary artery disease and approached the diagnostic accuracy of expert wall motion analysis; LAD LCX RCA ANY CAD WMS 71% 71% 70% 86% MDV 77% 68% 66% 80% p value p=NS p=NS p=NS p=NS Accuracy of MDV, but not WMS (p=NS) was affected by good vs. poor image
quality (82% vs. 73%, p=.OOl) and multi vs. single vessel disease (92% vs 72%, p=O.O2). Conclusions: MDV is a reproducible and quantitative measure of regional function which accurately predicts significant CAD during DbE. However, MDV remains dependent on image quality.
Meeting
of CSANZ
Al25
LONG TERM SURVIVAL AFTER AORTIC VALVE REPLACEMENT IN PATIENTS WITH LOW GRADIENT SEVERE AORTIC STENOSIS AND SEVERE LEFT VENTRICULAR SYSTOLIC DYSFUNCTION * J.J.as. Y huer. J B. Youne. I. Afiidl. The Cleveland Clinic Foundation, Cleveland, Ohio, USA. Objectives: The benefit of aortic valve replacement (AVR) for patients with severe aortic stenosis (AS) and low tiansvalvular gradients in the presence of severe left ventricular (LV) systolic dysfunction remains uncertam. previous reports of AVR m this lngh-risk group show Ixgh short and long-term mortality. We Identified 64 consecutne patients who underwent AVR Methods: between 1990 to 1998 with aortic valve area (AVA) 5 0.75 cm’, mean gradient 5 30mmHg and left ventricular ejection fraction (LVEF) < 35%. Climcal, echocardiograpic, cardiac catheterizabon and surgxal variables were analysed and patients followed for a mean of 2.8 f 2.3years. Results: There were 53 males/l I females, age = 70 + 9 years, 53% with prior myocardial infarction and 31% with prior coronary artery bypass surgery (CABG). Echocardiographic factors included: LVEF = 22 * 6%, AVA=0.62 & O.llcm*, and peak/mean gradients of 43 + 8 and 25 + 8 mmHg, respectively. Severe coronary artery disease (2 2 vessel &ease or left main) occurred in 66% and CABG was performed in 61% of patients. In-hospital mortality was 4.8%. By Kaplan-Meier analysis, l-year survival was 84% and 5-year survival was 64%. Long-term univariate predictors of mortality were age, relative
“Tricuspid regurgitation was detected in only 22 patients. Con&ions: 7) Diastolic, as well as systolii function, gender and pulmonary hypertension are determinants of FC. 2) Severity of MR is not a determinant of FC. Prospective studies are needed to better assess the significance of diastohc dysfunction in MR patients.
Scientific
risk
(RR)
=1.07
(95%
CI
=
1.01-1.14,
p=O.O3),
insulin
dependent diabetes mellitus RR=3.1 (95% CI = 1.01-9.79, p=O.O48) and right ventricular dysfunction RR=3.0 (95% CI=1.2-7.5, p=O.O2). Clinical followup was avadable in 43 of 45 long-term sm-v,vors. Mean NYHA functional class improved from 2.9 to 1.6 (p
AVR for patients with severe low transvalvular
gradient AS and
severe LV systolic dysfunction can be performed with acceptable in-hospital mortahty, favourable 1 and 5-year survival and a significant improvement in NYHA functional class.
TWENTY-EIGHT YEARS FOLLOW-UP OF PRIMARY AORTIC VALVE REPLACEMENT WITH ALLOGRAFTS - AN ECHOCABDIOGRAPHIC STUDY OF 613 PATIENTS. P. P&a. S. Burstow. M. O’Brien*. Departments of Echocardiography and Cardiac Surgery,
The Prince Charles Hospital, Brisbane, Qld. Since 1960s when aortic &grafts
(AA) have been introduced, !t has been
apparent that thx kind of aortic valve surgery offers many advantages over the prosthetic valves. The main concern regarding the AA is its durability. A”” of this study was to assess the contribuhng factors for long time uneventful longewty of AA and to defme potential failure factors 1” this group of patrents during the 28.
year follow-up. AA m@ntation was performed by a subcoronary techmque or a total mot replacement in a group of 1022 pts. (mean age 48 k 17 years, 669 male). l-he AA were cryopreserved (“=898) or “onvmble (“=124). Results: 30.day monality for the entire group was 3.0% (the last consecutive 352 pts all having root rdacement was 1.1%). Crude suw~val was 65% at >25 vears follow-uo. The re-op.&&on rate was 11.2% (n=l35) at a mean tune post surgery of 9.4 f 5.8 years. To assess the performance of AA, echocardiographic studies were nerfonned between 1996.1998 ,a 613 eatients (between 89 davs to 25 ,“ears .~oost
AA ““plantation, mean 6.7 years). Durmg that period, in 487 (59%) patxnts there
were no echocardiographic signs of either AA stenosis (AAS) or regurgdation (AAR). 42 patients (7%) had AAS and 81 (13%) AAR. There was no differences between AAS, AAR and normal AA in several valve- and procedure-related
detetinants (see Table). However, AA patients who died or had aortic valve re operation had larger aortic annulus size (recipients to donor difference) as compared to patienti with normal AA derived by echocardiogram (3.4 * 2.2 cm vs. i.3 i 2.2 Em, Pco.oot). AAS (n=42) AAR (n=8 1) Normal AA (n=490) Non-viable A&c Valve 0 3(4%) 6(1%) Clyopreserved Aorhc Valve 42(100%) 78(96%) 484(99%) Procurement time @IS) 14.3 k 8.1 14.8f7.5 15.2 + 8.5 Patients age (yrs) 41 I19 50+1t5 41+16 Age recipientidonor 14k23 20+23 15t21 Difference (yrs) I I I Aonic annulus 2.3 f 1.6 2.7 f 2.5 2.3 f2.3 Recipients/donor difference (cm) Conelusions: AA reolacement eives good lone term results at follow-uo. of UD 1 to 28 years. There was’s trend for-AAR”patxn&;nd those who ched or needed reoperation to be older and have blgger annulus diameter. No other specific patient