PREDICTION OF INDICATIONS FOR VALVE-REPLACEMENT AMONG ASYMPTOMATIC ORMINIMALLY SYMPTOMATIC PATIENTS WITH CHRONIC AORTIC REGURGITATION AND NORMAL LEFT-VENTRICULAR PERFORMANCE
Js. Borer et al., PREDICTION OF INDICATIONS FOR VALVE-REPLACEMENT AMONG ASYMPTOMATIC ORMINIMALLY SYMPTOMATIC PATIENTS WITH CHRONIC AORTIC REGURGITATION AND NORMAL LEFT-VENTRICULAR PERFORMANCE, Circulation, 97(6), 1998, pp. 525-534
Citations number
58
Categorie Soggetti
Peripheal Vascular Diseas",Hematology,"Cardiac & Cardiovascular System
Background-Optimal criteria for valve replacement are unclear in asymp
tomatic/minimally symptomatic patients with aortic regurgitation (AR)
and normal left ventricular (LV) performance at rest. Moreover, previo
us studies have not assessed the prognostic capacity of load-adjusted
LV performance (''contractility'') variables, which may be fundamental
ly related to clinical state. Therefore, 18 years ago, we set out to t
est prospectively the hypothesis that objective noninvasive measures o
f LV size and performance and, specifically, of load-adjusted variable
s, assessed at rest and during exercise (ex), could predict the develo
pment of currently accepted indications for operation for AR. Methods
and Results-Clinical variables and measures of LV size, performance, a
nd end-systolic wall stress (ESS) were assessed annually in 104 patien
ts by radionuclide cineangiography at rest and maximal ex and by echoc
ardiography at rest; ESS was derived during ex. During an average 7.3-
year follow-up among patients who had not been operated on, 39 of 104
patients either died suddenly (n=4) or developed operable symptoms onl
y (n=22) or subnormal LV performance with or without symptoms (n=13) (
progression rate=6.2%/y). By multivariate Cox model analysis, change (
Delta) in LV ejection fraction (EF) from rest to ex, normalized for De
lta ESS from rest to ex (Delta LVEF-Delta ESS index), was the stronges
t predictor of progression to any end point or to sudden cardiac death
alone. Unadjusted Delta LVEF was almost as efficient. Symptom status
modified prediction on the basis of the Delta LVEF-Delta ESS index. Th
e population tercile at highest risk by Delta LVEF-Delta ESS progresse
d to end points at a rate oi 13.3%/y, and the lowest-risk tercile prog
ressed at 1.8%/y. Conclusions-Currently accepted symptom and LV perfor
mance indications for valve replacement, as well as sudden cardiac dea
th, can be predicted in asymptomatic/minimally symptomatic patients wi
th AR by load-adjusted Delta LVEF-Delta ESS index, which includes data
obtained during exercise.