Pre- and postoperative cineangiocardiographic ventricular function

hemodynamic and assessment of left in patients with aortic

regurgitation

F. Herreman, M.D. A. Ameur, M.D. F. de Vernejoul, M.D. J. H. Bourgin P. Gueret, M.D. F. Guerin, M.D. M. Degeorges, M.D. Paris. France

Valvular surgery has evolved considerably during the past decade, making operations safer and valve dysfunction less frequent. However, such operations are still marred by a certain number of early deaths, incomplete results, and late postoperative deaths. Several investigators have attempted to define the long-term prognostic significance of various preoperative parameters.‘-’ Among the factors responsible for operative failures, myocardial status appears to be determinant. In aortic regurgitation (AR), the mechanical overloading caused by the regurgitation induces myocardial insufficiency which is often severe, as demonstrated by the decrease in left ventricular function (LVF) indices, measured by angiocardiography’ as well as by echocardiography.” These myocardial alterations have recently been confirmed by ultrastructural studies.‘- ’ The long-term postoperative course of these indices of LVF in AR has been the object of only a limited number of studies. Gault and associates” and Henry and colleagues” consider myocardial alterations to be irreversible. From the Laboratory of Hemodynamics Department of Cardiovascular Diseases Cochin, Paris, France. Received

for publication

June

30, 1978.

Accepted

for publication

Dec.

4, 1978.

Reprint requests: Dr. F. Herreman, laires. HBpital Cochin. 27 Rue FlYlIKe.

0002~8703/79/070063

+

and (Pr.

Cineangiocardiography, M. Degeorges), H&pita1

Service des Maladies du Fbg. St.-Jacques,

10$01.00/O

G 1979

The

Cardiovascu75014 Paris,

C. V. Mosby

Co.

In this study, hemodynamic and angiocardiographic parameters were assessedbefore and after valve replacement in order to provide evidence that, at least in some cases, myocardial insufficiency is reversible. Materials

and methods

A hemodynamic and angiocardiographic study was performed in 11 patients with AR prior to, and 14 months on the average (range: 7 to 25 months) following aortic valve replacement. There were 10 male patients and 1 female patient whose ages ranged from 21 to 62 years (mean: 39 I 14 years). The etiology was rheumatic in six patients, rheumatoid spondylitis in one, bacterial endocarditis in one, calcified bicuspid valve in one, Marfanoid valve in one, and unknown in one. In nine cases surgery was justified because of more or less severe symptoms of left ventricular failure with angina pectoris in two cases. Two asymptomatic patients were referred for surgery owing to markedly altered LVF with striking cardiac enlargement (CTR I 0.64). Cardiothoracic ratio was increased (10.50) in all patients but two. In all cases, valve correction was complete and the integrity of the mitral valve was confirmed. Preoperutively, all patients underwent left. and right cardiac catheterization after mild premedi-

American

Heart

Journal

63

Herreman

et al.

I. Pre- and postoperative results

Table

Patients 1

Age M-s) 38

2

62

3-i

21

4

33

5

41

6

49

7s

56

8

26

9t

21

1Ot.l Iii

23 54

surgery

Time - catheter (months)

Preop Postop Preop Postop Preop Postop Preop Postop Preop Postop Preop Postop Preop Postop Preop Postop Preop Postop Preop Postop Preop Postop Preop

iz 39 sd 14 iii Postop sd Controls fii 21 sd 13 P (Pre- vs. postop) P (Pre- vs. controls) P (Post- vs. controls)

1.5

25 0.5 19 3 15 1 15 1.5 14 1

8 5 7 1

13 0.5 17

1.5

AoSP (mm. Hg)

CTR CW

RR’ (ms.)

CI (L/min./M.!)

0.55 0.45 0.62 0.53 0.44 0.38 0.69 0.61 0.55 0.43 0.50 0.44 0.52 0.50 0.60 0.65 0.65 0.52 0.48

1250 840 720 720 680 620 710 600 720 650 730 620 880 620 750 740 650

2.5 4.2 3 2.65 3.2 3.7 2.4 2.85 2.2

125 130 140 145 1.35 105 120 105 160

3 3.2

115 145 150

10

0.49

3 8 1.8 1.4 14 5.4 -

0.64 0.60 0.57 0.09 0.51 0.09 0.40 0.05 NS 0.001 0.001

910

500 620 1000 780 784 210 698 110

744 149 NS NS NS

1.9

4.3 1.6 1.8 3.65 3.05 2.3 2.4 2.3 2.6 0.6 3.1 0.8 3.2 0.6 NS 0.05 NS

160 140 120 125 130 120 95 85 140 110 132 19 121

20 114 10 NS 0.05 NS

AoDP (mm. Hg)

EDP* (mm. Hg)

35 86 40 88 50 75 60 80 50 75 60

16 9 18 6 28

RF &) 52 73 74 75 -

12

20 5 25

100

60 90 40 85 50 80 50 66 60 70 50 9

20 IO 25 33 27 9 14

81 10

11

10 10 10

11 0.001

8 8.6 2.4 0.05

0.001

0.01

NS

NS

1.50 117

268 60 209 92 I58 125

78 -

199

33 149 103

60 72 -

179 101 100

68 65

168 94

-

74 69

51 -

20 5

78

LVSW, (g.m/M.‘l beat)

159

70 165 52 86 28 72 PO

67 10 -

0.01 0.01

NS

-

*EDP was assimilated to P,,, postoperatively. t = asymptomatic patients. $ = cardiothoracic ratio c 0.50. § = p&operative infarction. Abbreviations: CTR = cardiothoracic ratio; RR’ = cardiac cycle; CJ = cardiac index; AoSP = aortic systolic pressure; AoDP = aortic diastolic pressure; EDP = left ventricular end-diastolic pressure; RF = regurgitant fraction; LVSW, = total left ventricular stroke work; LVSW, = net left ventricular stroke work; LV,.,. = left ventricular mass; EDV = left ventricular end-diastolic volume; ESV = left ventricular end-systolic volume; EF = ejection fraction; AD = extent of shortening; LVET = left ventricular ejection time; VCF = mean velocity of fiber shortening; MLVER = mean left ventricular ejection rate; LIDI, = diastolic axis ratio; L/D, = systolic axis ratio; P,,, = mean pulmonary capillary pressure; W = mean; sd = standard deviation; preop = preoperative; post = postoperative.

cation with 5 to 10 mg. of diazepam. None of these patients had received cardiac tonic or diuretic drugs for at least 48 hours. Pressures were recorded with a Statham P 23 DB transducer. In one patient, the left ventricle (LV) could not be catheterized. In all cases but one, cardiac output was measured using Fick’s method. All patients also underwent right anterior oblique (RAO) single plane cineaortography (100 frames per second). The contrast medium (Radioselectan 76 per cent) was injected in a dose of 1.5 cm.“/Kg. over 3 to 4 seconds and an

64

electrocardiogram and aortic pressure were recorded simultaneously. Coronary arteriography was performed in only one patient 41 years of age, the others being less than 40 years old. The cineangiograms were displayed using a Tage Arno 35 mm. projector. Either the third or fourth cycle was studied so as to avoid the Starling effect initially and later myocardial toxicity and hypervolemia due to the contrast medium. Extrasystolic and post-extrasystolic cycles were excluded. All patients exhibited sinus rhythm. Left ventricular surface area was

July,

1979.

Vol.

98, No.

1

Assessment

of LV function in aortic regurgitation

LVSW, (‘.miM.‘/ beat)

LV,,,. (g/M.‘)

EDV (~rn.‘/M.~)

ESV (cm.3/M.1)

EF m

AD cw

LVET (ms.)

VCF (k-c/s.)

126 108 57 175 87 114 111 186 32 111 98 151 93 78 -

290 211 -

224 106 216 58 209 70 392 255 208 39 178 84 228 91 468

110 71 134 33 140 52 116 78 121 23 91 49 101 52 63 117 79 65 52 82 54 108 23 54 18 52 8 0.001 0.001 NS

49 66 62 56 67 74 30 30 58 60 51 58 44 57 13 -

22 36 34 28 36 45 14 15 24 32 24 31 20 30 30

0.60 1.37 1.07 0.87 1.02 1.74 0.39 0.55 0.76 1.17 0.77 1.31 0.62 1.40 0.10 -

33 65 32 21 37 23 46 13 51 19 65 6 NS 0.001 0.05

15 37 15 9 15 11 21 8 27 12 35 5.2 NS 0.001 0.05

360 260 320 320 350 260 370 280 320 270 320 240 330 220 330 305 320 320 280 270 300 270 320 20 270 30 275 28 0.01 0.01 NS

123 91 62 62 148 62 135 39 80 2.5 66 20 0.01 0.001 NS

350 202 188 64 203 132

124 174 231 89 157 60 74 8.8 NS 0.01 0.02

350 122 202 247 221 234 242 70 131 83 81 12 0.01 0.001 NS

measured by planimetry and LV volumes were calculated by the area-length method of Dodge and Sandler after adjustment for radiologic enlargement and distortion, the coefficient being determined by means of a grid positioned at the mid-thoracic thickness. The following parameters were determined on the basis of angiographic data: extent of shortening of the small axis (AD), expressed as a percentage of end-diastolic length; left ventricular end-diastolic and end-systolic volumes (EDV and ESV) expressed in cm.:‘/M.?, from which the stroke volume (cm.:I/M.?) was determined: SV = ESV - EDV; ejection fraction (EF) expressed as a percentage: EF = SV/EDV; mean left ventricular ejection rate (MLVER), or the quotient of EF and left ventricular ejection time (LVET) (MLVER = EF/LVET); regurgitant fraction (RF) determined from the SV values

American

Heart Journal

0.43 1.16 0.53 0.33 0.52 0.41 0.68 0.20 1.03 0.47 1.29 0.28 0.02 0.001 NS

MLVER 1.36 2.54 1.94 1.75 1.91 2.85 0.81 1.07 1.81 2.22 1.59 2.42 1.33 2.59 0.39 1.03 2.03 1.14 0.78 1.23 0.85 1.32 0.48 1.91 0.76 2.37 0.39 0.05 0.001 NS

L/D,,

L/D,

1.56 1.98 1.48 1.70 1.47 1.86 1.38 1.19 1.65 1.41 1.47 1.67 1.55 1.72 1.26

1.66 2.53 2.02 2.02 1.85 2.99 1.55 1.37 1.60 1.87 1.67 2.22 1.73 2.25 1.21 -

1.50 1.94 1.77 1.51 1.26 1.35 1.51 0.14 1.63 0.26 1.65 0.23 NS 0.05 NS

1.64 2.80 1.94 1.57 1.32 1.47 1.65 0.24 2.11 0.56 2.14 0.32 0.05 0.001 NS

obtained by angiography and by Fick’s method expressed as a percentage: RF = (We,,), (SV - SV,,,)/SV; mean velocity of circumferential fiber shortening (VCF) expressed in circumferences per second: VCF = AD/LVET; enddiastolic and end-systolic axis ratios (L/D,, and L/D,); left ventricular stroke work (LVSWT) expressed in g.m/M.Ybeat, determined from mean left ventricular or aortic systolic pressure (LVSP or AoSP) obtained by planimetry; and angiographic SV: LVSW, = LVSP x SV x 0.0136; net left ventricular stroke work obtained by subtracting EDP from LVSP: LVSW, = (LVSP - EDP) x SV x 0.0136. In five patients, left ventricular mass was evaluated from EDV and anterior wall thickness, the epicardial contour being delineated by the anterior interventricular artery. Postoperatively, right cardiac catheterization

65

Herreman

et al.

3.6 32 2,S-

2.4 Pre.ap.

NS Pre.op.

I,&

Post.op.

AOSP

[mm

MS]

AODP

[mdh]

P,O.OP

Po*t.w

p0st.w

3. Pre- and postoperative values of left ventricular enddiastolic volume (EDV), end-systolic volume (EST). and stroke volume (SV) (see Fig. 1 for explanation of symbols).

P~DzDP.

Fig. 1. Pre- and postoperative values of cardiothoracic ratio (CTR) and cardiac index (CI). The P values refer to the difference between pre- and postoperative measurements. N = mean normal value; Open circles = mean pre- and postoperative values * one standard deviation.

‘7

R.LOP.

Fig.

2.

I

Pm3t.w.

LVEDP

p,

patient with severe heart failure, angiography was not performed. The indications for postoperative control investigations were not selective in this series, patient acceptance and a follow-up of more than 6 months being the criteria used. Comparison between pre- and postoperative values was performed by means of Student’s t test for paired series and these values were also compared to those of 20 controls with no evidence of left ventricular abnormalities. Calculations were done on a Hewlett Packard HP 65 calculator. Results

\

NS

8

P,*.op

Poa.op

2. Pre- and postoperative values of aortic peak systolic pressure (AoSP), aortic diastolic pressure (AoBP), and left ventricular filling pressure: left ventricular end-diastolic pressure (LVEDP) before surgery and mean pulmonary capillary pressure (E) after surgery (see Fig. 1 for explanation of symbols). Fig.

and recording of aortic pressure were performed in all patients, combined with pulmonary arteriography in ten patients and aortography in five, clinical examination having definitely ruled out any suspicion of residual AR in the other six patients. LVF was evaluated from the levogram phase of pulmonary arteriography, the cycle chosen being the earliest possible before the fifteenth second so as to overcome the secondary effects of the contrast medium. The parameters studied were the same as before surgery. In one

66

Pre- and postoperative results are shown in Table I and in Figs. 1 to 5. Comparison of pre- and postoperative values for the various parameters is mentioned in each figure. Hemodynamic parameters. All patients improved following surgery and all but one became asymptomatic. Cardiac index (CI), significantly reduced prior to surgery (2.6 h 0.6 L./min./M.‘, p < 0.05) returned to normal (3.1 -t 0.8 L/min./ M.‘). Three patients, however, retained a markedly reduced cardiac output (CI 5 2.3 L./min./ M.‘). Pulmonary artery systolic pressure was normal prior to surgery and did not change postoperatively (24 f 6 vs 24 & 14 mm. Hg). The same was true of mean pulmonary capillary pressure (PC,,) (11 t 4 vs 11 * 8 mm. Hg). AoSP, slightly increased prior to surgery (132 -+ 19, p ==z0.05), returned to normal (121 * 20 mm. Hg), while mean aortic systolic pressure remained constant (117 h 21 vs 122 f 20 mm. Hg) as did systemic vascular resistance (1,685 ? 646 vs 1,557 + 388 dyns.s.cm.mI).

July,

1979,

Vol.

98, No.

I

Assessment

Aortic diastolic pressure (AoDP), severely reduced prior to surgery (p < O.Ol), reverted to normal (50 * 9 vs 81 + 10 mm. Hg). EDP, increased before valve replacement (p < O.Ol), with an inverted LV to capillary gradient in eight cases, reverted to normal (20 ? 5 vs 11 f 8 mm. Hg). Following surgery, p,.,, was assimilated to EDP. LVET, significantly increased before surgery (320 ? 20 msec., p < O.Ol), reverted to normal after surgery (270 & 30 msec.). The same was true of LVSW., which dropped from 165 +- 52 (p < 0.01) to 86 * 28 g.m./M.‘/beat and LVSW, which decreased from 135 t 39 (p < 0.001) preoperatively to 80 + 25 g.m./M.‘/beat postoperatively. Angiographic data. Left ventricular volumes were markedly increased prior to surgery (p < 0.001): EDV = 242 + 70 cm.‘/M.’ and ESV = 135 t 68 cm.‘/M.‘. These volumes declined significantly but did not return to normal levels following valve replacement: EDV = 131 +- 83 cm.‘/M.? (NS) and ESV = 76 I 75 cm:‘/M.’ (p < 0.01). In three patients ventricular volumes did not decrease. SV, also significantly increased before surgery: 108 * 23 cm//M.’ (p < 0.001) returned to normal: 54 f 18 cm//M.’ The preoperatively-augmented left ventricular myocardial mass (LV,,,,) (231 ? 89 g/M.‘, p < 0.01) declined after surgery but remained above the normal level (157 * 60 g/M.‘, p < 0.02). Determination of L/D,, and L/D, revealed that the abnormally spherical left ventricle (L/D,, = 1.51 + 0.14, p < 0.05; L/D, = 1.70 + 0.20, p < 0.001) assumed its normal shape after surgery (L/D,, = 1.63 * 0.26 and L/ D, = 2.11 t 0.56). LVF indices, which were all significantly (p < 0.001) depressed prior to surgery (AD = 21 + 8 per cent, EF = 46 + 13 per cent, VCF = 0.68 -+ 0.2 circ./sec., MLVER = 1.32 + 0.48) increased following surgery. However, AD and EF remained significantly (p < 0.05) low (AD = 27 & 12 per cent and EF = 51 f 19 per cent) whereas normalized LVF indices returned to virtually normal levels: VCF = 1.03 ? 0.47 circ./sec. and MLVER = 1.91 * 0.76. Examination of individual values for these parameters revealed that preoperative LVF indices were normal in only two patients, moderately decreased in two others, and markedly

American

Heart

Journal

EF

of LV function

in aortic

regurgitation

AD[%I

b/o]

50

30

15

NS 0

Pre.op.

NS a

post .OP.

Fig. 4. Pm- and postoperative values (EF) and extent of circumferential fiber Fig. I for explanation of symbols).

Pre.op.

Post.op.

of ejection shortening

fraction (AD) (see

I ULVER

3at

5 .---

-

-N

?.25c

.5- (

d 0

P -z 0,01 ‘r*.op. POI1.OP.

P