Predicting outcome after valve replacement.

OBJECTIVE: To identify the key predictors of performance on a 6-minute walk and health-related quality of life (QOL) one year after cardiac valve replacement and to use the predictors to guide clinical practice and optimise outcome. DESIGN: Prospective cohort study. SETTING: Tertiary cardiothoracic centre in the UK. PATIENTS: 225 patients having first time valve replacement with a mean age 67.1 (SD 12.1) years. MAIN OUTCOME MEASURES: Mortality, morbidity, NYHA, performance on a 6-minute walk and health-related QOL one year after surgery. RESULTS: One year after valve replacement 90% of patients were alive and free from a major event related to their surgery. NYHA category fell by 0.6. Performance on a 6-minute walk improved by 42% and QOL improved on all subscales and both composite scores of the SF-36 QOL questionnaire. Although physical QOL scores improved they did not normalise, unlike the mental QOL scores which were near normal on both occasions. Independent baseline predictors of 6-minute walk performance at one year were baseline walk performance, age and belief in surgery as a treatment. Independent baseline predictors of one year physical QOL were baseline physical QOL and walk performance. Independent baseline predictors of one year mental QOL were depression, baseline mental QOL and age, with age having a positive effect. CONCLUSIONS: One year after valve replacement patients can expect a significant improvement in their exercise tolerance and QOL but their physical QOL is unlikely to be normal. Outcome may be improved by treating depression and modifying negative illness beliefs preoperatively.

A randomized comparison of the MCRI On-X and CarboMedics Top Hat bileaflet mechanical replacement aortic valves: early postoperative hemodynamic function and clinical events.

OBJECTIVE: This study compared hemodynamic function and clinical events in consecutive patients randomly assigned to receive a wholly supra-annular replacement valve or a valve with an intra-annular component. METHODS: Fifty-two patients with an average age of 62 years (range 40-74 years) were sized for both a CarboMedics Top Hat valve (CarboMedics Inc, Austin, Tex) and an MCRI On-X valve (Medical Carbon Research Institute, LLC, Austin, Tex) before random assignment to receive either valve type. Echocardiographic and clinical assessments were performed in the immediate postoperative period and at 1 year. RESULTS: The mean effective orifice areas were 1.41 +/- 0.42 cm2 for the Top Hat and 2.17 +/- 0.78 cm2 for the On-X (P < .0001). The mean pressure differences were 12.2 +/- 4.4 mm Hg and 6.9 +/- 3.6 mm Hg, respectively (P < .0001). New York Heart Association functional class was better with the On-X than the Top Hat valves, but there were no differences in clinical events, regression of left ventricular mass, or measures of hemolysis. CONCLUSION: The partially intra-annular MCRI On-X valve was hemodynamically superior to the wholly supra-annular CarboMedics Top Hat valve. However, there were no differences in early clinical outcomes between the two valve types.

Prediction of symptom-onset in aortic stenosis: a comparison of pressure drop/flow slope and haemodynamic measures at rest.

To compare the pressure drop/flow slope with peak and mean pressure drop, effective orifice area and aortic valve resistance for the prediction of symptom-onset we performed resting and dobutamine stress echocardiography in 49 asymptomatic patients with aortic stenosis (peak aortic velocity>2.5 m/s). The end-point was progression to symptoms requiring surgery and patients were followed for a mean 21.2 (5.2) months. A total of 23 (47%) patients progressed to symptoms requiring aortic valve replacement and 26 remained asymptomatic. There was no significant difference in age, gender, fractional shortening or the presence or absence of coronary artery disease between these groups. There were differences in peak aortic velocity (P<0.0001), peak and mean pressure drop (P<0.0001), effective orifice area (P=0.03), aortic valve resistance (P=0.001) and pressure drop/flow slope (P<0.0001). On Cox regression analysis, the pressure drop/flow slope (P<0.0001), peak aortic velocity (P=0.005) and peak pressure gradient (P=0.02) were independent predictors. Mean event-free survival at 2 years for peak velocity >4.0 m/s was 17% and for pressure drop/flow slope >0.10 mmHg/ms(-1) was 20%. Of 13 patients reporting symptoms during dobutamine stress, 10 (77%) developed spontaneous symptoms during follow-up compared with 13 of 36 (36%) with no symptoms (P=0.11). The pressure drop/flow slope is a better independent predictor of symptom onset than resistance, mean pressure difference and effective orifice area, but is similar to peak velocity.

Long axis excursion in aortic stenosis.

OBJECTIVES: To examine long axis excursion in patients with all grades of aortic stenosis and preserved transverse systolic function, and to compare long axis excursion in symptomatic with that in asymptomatic severe aortic stenosis. DESIGN: Prospective comparative study. SETTING: Regional cardiothoracic centre. PATIENTS: 78 patients with all grades of aortic stenosis and normal fractional shortening and ejection fraction were studied. There were two comparison groups, 10 age matched normal subjects and 14 patients with aortic stenosis and fractional shortening < 26%. METHODS: Aortic valve function and left ventricular mass were assessed echocardiographically. M mode measurements of long axis excursion at the septal and lateral sides of the mitral annulus were taken. RESULTS: There were significant differences between the groups in long axis excursion at both the septal (p < 0.0001) and lateral sides of the mitral annulus (p = 0.002 by analysis of variance). Long axis excursion was independently related to both left ventricular mass index (p = 0.001) and the grade of aortic stenosis (p = 0.002). Comparing patients with severe aortic stenosis with and without symptoms, there were significant differences in effective orifice area (p = 0.02 ) and long axis excursion at the lateral side of the mitral annulus (p = 0.04), but not in fractional shortening, ejection fraction, or peak or mean pressure difference. CONCLUSION: In patients with aortic stenosis, long axis excursion is reduced even in the presence of normal fractional shortening or ejection fraction. It is lower in patients with symptomatic compared with asymptomatic severe aortic stenosis and may be of use in predicting the onset of symptoms.

The relation between transaortic pressure difference and flow during dobutamine stress echocardiography in patients with aortic stenosis.

OBJECTIVE: To investigate the relation between transaortic pressure difference and flow in patients with aortic stenosis. METHODS: 50 asymptomatic patients with all grades of aortic stenosis were studied using dobutamine stress echocardiography. Individual plots of mean pressure drop against flow were drawn. Comparisons were made between grades of aortic stenosis as defined by the continuity equation. RESULTS: A significant linear relation between pressure difference and flow was found in 34 patients (68%). There was a significant curvilinear relation in four (8%), while no significant regression line could be fitted in 12 (24%). In the 34 patients with linear fits, the slopes (mean (SD)) were 0.08 (0.07) in mild, 0.10 (0.04) in moderate, and 0.22 (0.16) in severe aortic stenosis (p = 0. 0055). CONCLUSIONS: Transaortic pressure difference can be related directly to flow in many patients with all grades of aortic stenosis. However, there are individual differences in slope and intercept suggesting that resistance calculated at rest may not always be representative. Raw pressure drop/flow plots may be an alternative method of describing valve function.

How often do we operate too late in aortic stenosis?

The management of asymptomatic severe aortic stenosis remains controversial. Despite a good outcome in terms of mortality, the left ventricle may not recover fully after aortic valve replacement and patients may have impaired exercise ability. Routine assessment of the left ventricle is dominated by transverse systolic function to the relative neglect of long-axis and diastolic function. Long-axis dysfunction develops earlier than transverse dysfunction and may correlate with exercise ability. Reported symptoms can be unreliable and exercise testing reveals significant limitation in many apparently asymptomatic patients. Exercise testing and echocardiographic markers of early LV systolic dysfunction may help to refine the timing of surgery in patients with apparently asymptomatic severe aortic stenosis.

Relative power of clinical, exercise test, and angiographic variables in predicting clinical outcome after myocardial infarction: the Newham and Tower Hamlets study.

The interrelations of clinical, exercise test, and angiographic variables and their relative values in predicting specific clinical outcomes after myocardial infarction have not been fully established. Of 302 consecutive stable survivors of infarction, 262 performed a predischarge submaximal exercise test. In the first year after infarction patients with a "positive" exercise test were 13 times more likely to die, 2.8 times more likely to have an ischaemic event, and 2.3 times more likely to develop left ventricular failure than patients with negative tests. Patients with positive exercise tests underwent cardiac catheterization. Features of the history, 12 lead electrocardiogram, in-hospital clinical course, exercise test, and left ventricular and coronary angiograms that predicted these clinical end points were identified by univariate analysis. Then multivariable analysis was used to assess the relative powers of all variables in predicting end points. Certain features of the exercise test remained independent predictors of future ischaemic events and the development of overt left ventricular failure, but clinical and angiographic variables were more powerful predictors of mortality. Because the exercise test is also used to select patients for angiography, however, the results of this study strongly support the use of early submaximal exercise testing after infarction.