1. Dr M B Connellan Stellenbosch University
Severe Aortic Incompetence and Severe Left Ventricular Dysfunction: The Surgical Options
Dr M B Connellan
Stellenbosch University

2. The Options: Severe AI with Severely decreased EF:
Medical management
Aortic valve surgery
Transplantation
Factors to consider:
Natural history
Outcome with medical management
Operative morbidity and mortality
Long term prognosis after surgery
Availability and prognosis with transplantation

3. Natural History Asymptomatic patients with preserved EF
81% 5 yr survival
5-6% per year will become symptomatic
Symptomatic patients (NYHA Class III & IV)
impaired LV function
Annual mortality 25%
5yr mean survival after onset angina
2yr mean survival after onset CCF
EF most important prognostic factor

4. Pathogenesis NHYA Class I Class II Class III Class IV
LV dilation without increase in wall thickness
Volume overload
Class II
Eccentric hypertrophy
Volume and pressure overload
Class III
Reduced contractility
Decrease in fractional shortening
Class IV
Further decrease in fractional shortening
Wall thinning, myocardial fibrosis

5. Medical Management Nifedipine and ACE inhibitors
Reduce LV wall stress and volumes
May prolong interval to surgery
Not indicated in symptomatic patients with decreased EF- they require surgery
No contemporary studies comparing medically managed patients with decreased function to surgery

6. Surgery Typically poor outcome in patients with EF < 35%
Mortality rates 14-25%
Variable outcome after discharge
EF improvement average 5%
30% survival at 10yrs

7. Surgical improvements over time
Myocardial protection
Blood cardioplegia
Antegrade and retrograde (routinely at Cleveland)
TEE intraoperatively
Lower gradient prosthetic valves
Perioperative management
phosphodiesterase inhibitor
Assist devices
Post operative medical therapy
Biventricular synchronous pacing
Implantable cardioverter-defibrillators

8. Surgery Improvement in results over time n 30 d 1yr 5yr 10yr <198024 76 71 59 31 35 86 75 66 38
>1990 34
100 97 84
McCarthy PM. Aortic valve surgery in patients with left ventricular dysfunction. Semin Thorac Cardiovasc Surg 14(2): ,2002

9. Hospital mortality in propensity-matched patients across the clinical experience
Bhudia SK et al. Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction. J Am Coll Cardiol 2007;49:

10. Long term survival 1973 10yr survival 20% 1985 10yr survival 49%
After 1985 survival approaching 60%
After 1985 propensity matched survival
1yr
5yrs
10yrs
Severe LVD
92%
79%
51%
Nonsevere LVD
96%
83%
55%
Bhudia SK et al. Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction. J Am Coll Cardiol 2007;49:

11. Survival in propensity matched patients undergoing surgery in 1985 and beyond

12. Surgery 72 patients Severe AI EF <40% age 59.5yrs EF 28% LVED
66.0mm
LVES
51.9mm
X-clamp
65min
CPB time
88min
Chukwuemeka, A et al. Aortic valve replacement: a safe and durable option in patients with impaired left ventricular systolic function. Eur J Cardiothorac Surg 2006;29:

13. Surgery Peri-operative results: Number 72 Mortality 1.4% LOS 12.5%
IABP
6.9%
LOS:
inotropes or mechanical devices for >30min to maintain BP > 90mmHg with cardiac index <2.2L/min/m2

14. Surgery 1yr 5yr 10yr Death 99% 81% 61% Cardiac death 98% 93% 73%
Freedom from clinical events
1yr
5yr
10yr
Death
99%
81%
61%
Cardiac death
98%
93%
73%

15. Surgery 31 patients: 188 patients: >80mm <80mm LVED 83.7 66.5
Severe AI with LVED> 80mm
188 patients:
Severe AI with LVED>80mm
>80mm
<80mm
LVED
83.7
66.5
LVES
63.2
45.3 EF
43.2
53.6
CABG
6.5
17.6
Mortality 0%
5.6%
10 yr
71%
70%
Klodas E et al.Aortic regurgitation complicated by extreme left ventricular dilation:long-term outcome after surgical correction. J Am Coll Cardiol 1996;27:670-7

16. Surgery EF improvement post surgery- comparable in both groups
>80mm - 50% had persistant LVED>60mm
<80mm – 19% had persistant LVED>60mm
Combined multivariate analysis- poor EF still a predictor for late mortality

17. Late survival according to ejection fraction

18. Surgery Predictors of poor outcome Bhudia et al Chukwuemeka et al
severe LV dysfunction predictor of early and late mortality in early groups
Later groups EF did not seem to play a role in outcome
Chukwuemeka et al
No independent predictors of mortality, short or long term
Klodas et al
No early independent predictors of mortality
EF independent predictor of long term mortality

19. Surgery
Chaliki HP et al. Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function. Circ 2002;106:

20. Surgical management Preoperative Intraoperative Appropriate work up
Optimisation of patient
afterload reduction- Na nitroprusside
Inotropes- dobutamine
Intraoperative
Meticulous myocardial protection
Blood cardioplegia
Antegrade and Retrograde cardioplegia
Efficient surgery
Valve replacement vs repair

21. Surgical management Intraoperative Post operative Transesophageal echo
Experienced anaesthesia
Timeous use of IABP, assist devices
Post operative
Invasive monitoring- Swann Ganz
Appropriate inotrope usage
Attentive ICU care

22. Transplantation Valvular disease 3% of heart transplants
Valvular transplantation
mortality 9-16%
5 yr survival 70-80%
Resource intensive
ISHLT (international society for heart and lung transplantation)
Survival
1yr
5yr
10yr
15yr
80%
66%
47%
29%

23. Aortic valve surgery vs Transplantation
Hertz MI et al. The registry of the International Society for Heart and Lung Transplantation: Nineteenth official report J Heart Lung Transplant. 21:950,2002

24. AHA/ACC Guidelines severe AR irrespective of LV systolic function.
Class I
1. AVR is indicated for symptomatic patients with
severe AR irrespective of LV systolic function.
2. AVR is indicated for asymptomatic patients with
chronic severe AR and LV systolic dysfunction (ejection
fraction 0.50 or less) at rest.
3. AVR is indicated for patients with chronic severe AR
while undergoing CABG or surgery on the aorta or
other heart valves.

25. Summary Dismal outcome if medically managed
Surgical outcomes have improved over time, no longer prohibitive
Long term out-look dependent on pre-operative EF
High risk patients may need further mechanical support- IABP, VAD