Author + information
- Received October 23, 1984
- Accepted November 14, 1984
- Published online April 1, 1985.
- ↵*Address for reprints: John Ross, Jr., MD, Division of Cardiology, Room 2024, Basic Science Building, La Jolla, California 92093.
In the management of patients with valvular heart disease, an understanding of the effects of altered loading conditions on the left ventricle is important in reaching a proper decision concerning the timing of corrective operation. In acquired valvular aortic stenosis, concentric hypertrophy generally maintains left ventricular chamber size and ejection fraction within normal limits, but in late stage disease function can deteriorate as preload reserve is lost and aortic stenosis progresses. In this setting, even when the ejection fraction is markedly reduced (< 25%), it can improve to normal after aortic valve replacement, suggesting that afterload mismatch rather than irreversibly depressed myocardial contractility was responsible for left ventricular failure. Therefore, patients with severe aortic stenosis and symptoms should not be denied operation because of impaired cardiac function.
In chronic severe aortic and mitral regurgitation, operation is generally recommended when symptoms are present, but whether to recommend operation to prevent irreversible myocardial damage in patients with few or no symptoms has remained controversial. In aortic regurgitation, left ventricular function generally improves postoperatively, even if it is moderately impaired pre-operatively, indicating correction of afterload mismatch. Most such patients can be carefully followed by echocardiography. However, in some patients, severe left ventricular dysfunction fails to improve postoperatively. Therefore, when echocardiography studies in the patient with severe aortic regurgitation show an ejection fraction of less than 40% (fractional shortening < 25%) plus enlarging left ventricular end-diastolic diameter (approaching 38 mm/m2 body surface area) and end-systolic diameter (approaching 50 mm or 26 mm/m2), confirmation of these findings by cardiac catheterization and consideration of operation are advisable even in patients with minimal symptoms.
In chronic mitral regurgitation, maintenance of anormal ejection fraction can mask depressed myocardial contractility. Pre- and postoperative studies in such patients have shown a poor clinical result after mitral valve replacement, associated with a sharp decrease in the ejection fraction after operation. This response appears to reflect unmasking of decreased myocardial contractility by mitral valve replacement, with ejection of the total stroke volume into the high impedance of the aorta (afterload mismatch produced by operation). Therefore, when echocardiographic studies in patients with severe mitral regurgitation show an ejection fraction of less than 55% (fractional shortening < 30%), an end-diastolic diameter approaching 75 mm and an end-systolic diameter approaching 2.6 mm/m2body surface area, it seems advisable to undertake operation to prevent the development of irreversible myocardial damage, even if symptoms are few or absent.
- Received October 23, 1984.
- Accepted November 14, 1984.
- American College of Cardiology Foundation