Four years follow-up study in patients with Takayasu arteritis and severe aortic regurgitation; assessment by echocardiography

International Journal of

cardiology International Journal of Cardiology 54 Suppl. (1996) SI73-S176

Four years follow-up study in patients with Takayasu arteritis and severe aortic regurgitation; assessment by echocardiography Yuji Hashimoto·, Mamoru Tanaka, Akihiro Hata, Tsunekazu Kakuta, Yoshiaki Maruyama, Fujio Numano The Third Department of Internal Medicine. Tokyo Medical and Dental University. School of Medicine. 1-5-45. Yushima. Bunkyo-ku. Tokyo. Il3 Japan

Abstract

We prospectively performed the follow-up study in II female patients with Takayasu arteritis and severe aortic regurgitation by echocardiography. A mean follow-up period was 4 years. The inflammatory state was controlled in all patients. Antihypertensive agents including f1-blocker were administered in nine patients. Heart failure did not progress in all patients except one. No candidate for cardiac surgery appeared during the follow-up period. Aortic root diameter, left atrial, left ventricular end-diastolic and end-systolic dimensions, wall thickness, left ventricular mass, and percent fractional shortening of the left ventricle showed no significant change in echocardiography. These data indicate that left ventricular disturbance might be slowly progressive in patients with Takayasu arteritis and severe aortic regurgitation. Systemic hypertension and the inflammatory state should be well controlled in managing the patients. f1-blocker might be useful in some patients with Takayasu arteritis and severe aortic regurgitation. Further follow-up is necessary for the decision of the cardiac surgical indication.

Keywords: Takayasu arteritis; Aortic regurgitation; Follow-up; Echocardiography; Left vetricular hypertrophy

1. Introduction

Cardiac events are recently the most common cause of death in patients with Takayasu arteritis [1-3]. The major cardiac involvements of this disease include aortic regurgitation, hypertensive heart disease, and coronary artery disease. Many difficulties are present in the medical and the surgical management of patients with Takayasu arteritis and severe aortic regurgitation. The replacement of the dilated and affected aorta besides

the aortic valve replacement is often necessary in the surgical correction [4]. In 1990, we prospectively started a follow-up study of patients with Takayasu arteritis and severe aortic regurgitation by echocardiography to establish a guideline for the management and the operative indication. This is the first preliminary report of the follow-up study. 2. Materials and methods 2.1. Study subjects

• Corresponding author, Tel.: +81 3 58035231; fax: +81 3 58030133.

The first examination was performed from 1990

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Table I Study subjects Patients Age Follow-up period

Eleven female patients with Takayasu arteritis and severe aortic regurgitation 49 ± 9 years (35-63 years)" 4.0 ± 0.8 years (3.1-5.3 years)

IOn the second examination.

through 1992. We could obtain echocardiographically adequate echocardiograms in 48 patients with Takayasu arteritis. In these patients, 14(29%) Takayasu arteritis patients had severe aortic regurgitation. The second examination was done from 1994 through 1995. Two patients died during this period. One died suddenly. The other

died suddenly one month after the Bentall's operation. One patient dropped out. After exclusion of these three patients, we re-examined II patients with Takayasu arteritis and severe aortic regurgitation by echocardiography. All patients were female with a mean age of 49 ::I:: 9 years. A mean follow-up period was 4.0 ::I:: 0.8 years (Table I). Symptoms were defined as heart failure according to the New York Heart Association (NYHA) functional class. Four out of II patients received prednisolone. Nine patients took a calcium antagonist and/or other antihypertensive agents. As an interest, {3blocker was carefully administered to 3 patients (patient numbers 2, 6, and 8 in Table 2). Nine patients received digitalis and/or diuretics.

Table 2 Patients data Patient No.

2 3 4 5 6 7 8 9 10 II

Exam.

1st 2nd 1st 2nd 1st 2nd 1st 2nd 1st 2nd 1st 2nd 1st 2nd 1st 2nd 1st 2nd 1st 2nd 1st 2nd

NYHA class

I I I I I II II III I I I I I I I I I I II II I II

CRP" (mgldl)

<0.3 <0.3 0.3 <0.3 + 0.9 <0.3 <0.3 2+ 1.7 + <0.3 /

2.8 + 1.5

Echocardiographic data AoD (mm)

LAD (mm)

LVDd (mm)

LVDs (mm)

IVST (mm)

LVPWf %FS (%) (mm)

29.6 30.7 30.9 31.5 34.6 35.6 32.7 33.1

39.5 33.2 30.9 32.7 34.6 36.3 43.2 49.4

/

/

37.0 49.0 46.0 32.7 30.9 38.2 38.2 29.3 28.4 28.7 31.3 40.7 43.8

39.5 22.8 26.7 31.5 37.0

43.2 45.4 49.4 45.7 43.8 44.4 45.7 51.9 53.0 48.8 53.0 52.5 53.7 56.8 55.4 55.4 48.5 43.2 38.9 38.9 59.3 61.5

26.5 30.6 30.2 26.5 23.5 21.6 30.9 32.5 32.1 26.5 32.7 33.2 35.4 37.0 30.8 35.8 25.7 25.9 22.2 250 45.7 41.3

13.6 13.6 19.8 18.8 9.4 11.1 9.9 10.9 9.9 11.1 9.2 11.1 13.4 15.4 15.4 13.8 15.4 17.3 16.1 14.4 9.9 11.1

13.6 13.6 17.3 16.3 11.2 9.9 9.9 8.9 9.9 11.1 10.0 9.3 10.9 13.6 17.3 15.6 12.4 15.8 13.6 13.6 9.3 11.1

/

44.4 33.7 40.7 38.3 46.3 37.0 33.1

38.7 32.6 38.9 42.0 46.4 51.4 32.4 37.4 39.4 45.7 38.3 36.8 34.1 34.9 44.4 40.2 47.0 40.1 42.9 40.3 22.9 32.9

LVM (g) 285 301 491 449 260 200 246 238 252 251 255 252 283 466 321 517 470 378 319 279 210 368

Exam., examination; CRP, C-reactive protein; AoD, aortic root diameter; LAD, left atrial dimension; LVDd, left ventricular end diastolic dimension; LVDs, left ventricular end systolic dimension; IVST, interventricular septal thickness; LVPWf, left ventricular posterior wall thickness; %FS, percent fractional shortening of the left ventricle; LVM, left ventricular mass; Ist, the first; 2nd, the second. "CRP was expressed as -, +, 2+, ... on the first examination.

Y. Hashimoto et al. / International Journal of Cardiology 54 Suppl. (1996) S/73-S/76

2.2. Echocardiography

We used a commercially available echocardiographic machine with color Doppler capability, Toshiba SSH-I60A equipped with a 2.5-or 3.75MHz transducer. Aortic root diameter, left atrial dimension, interventricular septal thickness, left ventricular posterior wall thickness, left ventricular end-diastolic and end-systolic dimension, were measured from the standard M-mode echocardiogram at a paper speed of 10 cm/s according to the recommendations of the American Society of Echocardiography [5]. The percent fractional shortening of the left ventricle was derived as: [(left ventricular end-diastolic dimension-left ventricular end-systolic dimension)/left ventricular end-diastolic dimension] x 100. Left ventricular mass was calculated using the following formula introduced by Devereux et al. [6]: left ventricular mass (g) 1.04 x [(interventricular septal thickness + left ventricular end-diastolic dimension + left ventricular posterior wall thickness)3 - (left ventricular end-diastolic dimension)3] - 13.6.

=

2.3. Recognition of severe aortic regurgitation by color Doppler echocardiography

Severity of aortic regurgitation was assessed by color flow mapping technique in the apical longaxis view or the apical five-ehamber view [7] and the measurement of the ratio of the regurgitant jet height to the left ventricular outflow tract height in the parasternal long-axis view [8]. Aortic regurgitation was classified as severe if the regurgitant jet extended beyond the papillary muscle and the ratio of the regurgitant jet to the outflow tract height was> 0.5. All 11 patients had severe aortic regurgitation on both examinations. 2.4. Serological examination

C-reactive protein was measured on the first and the second examinations. 2.5. Statistical analysis

All values were expressed as the mean ± one standard deviation. Data were compared using a

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paired two-tailed t test. A P value < 0.05 was considered significant. 3. Results

All 11 patients had a low grade heart failure (NYHA functional class I or class II) on the first examination. Only one patient progressed from NYHA functional class II to class III on the second examination. The inflammatory state was well or fairly controlled in all patients on both examinations. Echocardiographically, aortic root diameter (34.6 ± 16.4 mm - 34.9 ± 5.6 mm; P NS), left atrial dimension (34.6 ± 5.9 mm - 38.1 ± 6.8 mm; P = NS ), left ventricular end-diastolic dimension (49.5 ± 6.1 mm - 50.2 ± 6.9 mm; P NS ), left ventricular end-systolic dimension (30.5 ± 6.5 mm - 30.5 ± 6.0 mm; P = NS ), interventricular septal thickness (12.9 ± 3.5 mm 13.5 ± 2.8 mm; P NS ), left ventricular posterior wall thickness (12.3 ± 2.9 mm 12.6 ± 2.7 mm; P NS ), percent fractional shortening of the left ventricle (38.7 ± 7.0% 39.5 ± 5.7%; P NS), and calculated left ventricular mass (308 ± 91 g - 336 ± 106 g; P = NS ) showed no significant change during the follow-up period. All patients data on both examinations were shown in Table 2.

=

=

=

=

=

4. Discussiou

No significant symptomatic and echocardiographic changes were shown in the 11 patients with Takayasu arteritis and severe aortic regurgitation in the present follow-up study. We had no candidate for cardiac surgery during this period. Aortic regurgitation and left ventricular deterioration might be slowly progressive in patients with Takayasu arteritis, if systemic hypertension or inflammatory state could be sufficiently controlled. As an interest, tl-blocker was carefully administered to three patents (patient numbers 2, 6, 8). Although tl-blocker is considered as a contraindication in patients with severe aortic regurgitation in general, it is not likely that tl-blocker

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Y. Hashimoto et al./lmernational Journal of Cardiology 54 Suppl. (1996) S173-S176

deteriorated aortic regurgitation or left ventricular function in these 3 patients during the 4 years follow-up period. We reported that the characteristics of the left ventricular geometry in patients with Takayasu arteritis and severe aortic regurgitation reveals concentric left ventricular hypertrophy in echocardiography [9J. In addition, myocardial damage is present in the hypertrophied left ventricle in scintigraphy [lOJ. Co-existing afterload increase due to long-standing systemic hypertension is thought to be a causative factor in these phenomena in patients with Takayasu arteritis and severe aortic regurgitation. It has been reported that l3-blocker is effective for left ventricular hypertrophy in systemic hypertension [11-12J. l3-blocker might be useful in some patients with Takayasu arteritis and left ventricular hypertrophy, independent of co-existing aortic regurgitation. In conclusion, no remarkable progression was shown in patients with Takayasu arteritis and severe aortic regurgitation during 4 years follow-up period. Afterload reduction (anti-hypertensive) therapy, in addition to the control of the inflammatory state, was thought to be important in managing the patients. l3-blocker might be effective in some patients with Takayasu arteritis and severe aortic regurgitation. We could not reach a conclusion about the decision of the time of the cardiac surgery in patients with Takayasu arteritis and severe aortic regurgitation from the present study. Four years follow-up is not long enough. Further follow-up study is necessary.

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