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American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

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Correction of Aortic Valve Stenosis: Is it Effective to Improve Left Ventricular Functions and Reduce Its Mass?

Hamdy D. Elayouty*, Magdy Ibrahim Wahdan, Marwan Hassan Elkasas, Hany Salman Fiesal, Eiman M. Altahawi

Department of Cardiothoracic Surgery, Suez Canal University, Ismailia, Egypt

Abstract: Background: Aortic valve stenosis causes gradual obstruction to left ventricular outflow tract. It is a common valvular disease that carries many life threatening complications. We hypothesized that the reduction or elimination of the pressure gradient across the aortic valve after correction of the stenotic lesion would lead to regression of left ventricular mass and improve left ventricular functions. Aim of the work is to assess the effectiveness of the correction and factors controlling these changes in left ventricular mass index and functions. Methods: preoperative and postoperative Electro-cardiography and echocardiography were performed for all patients. The corrective procedures included aortic valve replacement, balloon aortic valvuloplasty and open valve repair. Results: Sixty patients had correction of aortic valve stenosis (44 males, 16 females). ECG score preoperatively ranged between3 and 9 with a mean of 6 ± 1.63. Postoperatively, it ranged between 0 and 6 and mean of 3 ± 0.7. The mean LVED/BSA was reduced from 32.52 preoperatively to 30.41 postoperatively. The mean interventricular septal thickness index was reduced by 1.03. The mean left ventricular posterior wall thickness index was reduced by 0.99. Mean left ventricular mass index was reduced by 31.86 gm. The mean ejection fraction increased by 6.45. Mean trans-aortic peak gradient was reduced by 41.36 mmHg. Conclusions: Correction of aortic valve stenosis improves systolic and diastolic left ventricular function and a reduction in left ventricular mass index. Aortic root enlargement procedures can be safely avoided.

Keywords: aortic stenosis, correction of aortic stenosis, left ventricular mass index, ejection fraction

Received November 19, 2013; Revised December 20, 2013; Accepted January 12, 2014

Citation: Hamdy D. Elayouty, Magdy Ibrahim Wahdan, Marwan Hassan Elkasas, Hany Salman Fiesal, Eiman M. Altahawi, Correction of Aortic Valve Stenosis: Is it Effective to Improve Left Ventricular Functions and Reduce Its Mass?. American Journal of Cardiovascular Disease Research, 2 (1). 1-3. January 2014. doi:10.12691/ajcdr-2-1-1

1. Introduction

Aortic valve stenosis causes gradual obstruction to left ventricular outflow left ventricular hypertrophy may result in a large pressure gradient across the stenotic valve. Subsequent elevation of left ventricular end-diastolic pressure is a marker of diminished compliance and diastolic dysfunction of the left ventricle. As the left ventricle becomes less compliant, onset of atrial fibrillation may result in clinical worsening and ventricular decompensation.

We hypothesized that the reduction or elimination of the pressure gradient across the aortic valve after correction of the stenotic lesion would lead to regression of left ventricular mass and improve left ventricular functions. Aim of current study is to assess the effectiveness of the correction and factors controlling these changes in left ventricular mass index and functions.

2. Methods

This prospective randomized study included 60 patients with isolated aortic valve stenosis treated during the last 3 years. The purpose of intervention was to eliminate left ventricular outflow tract obstruction to minimize pressure gradient or eliminate it. This was achieved by aortic valve replacement in 52 cases, balloon aortic valvuloplasty in 4 cases of congenital aortic stenosis and open aortic valve repair in young females with rheumatic valve stenosis. A formal consent was written by each patient after detailed explanation of the procedure. Each patient had electrocardiography and echocardiography preoperatively and three months postoperatively.

2.1. Data Management and Statistical Analysis

The relations between the dependent and independent variables were studied using the Chi-Square test and the T-test. The significant variables were subjected to multiple logistic regression analysis.

3. Results

Sixty patients had correction of aortic valve stenosis (44 males, 16 females). Age ranged between several months and 43 years. The ECG score decreased postoperatively. The mean decrease was 3.3 ± 1.1. this reduction was statistically significant. Pre-and postoperative clinical and echocardiographic parameters were significantly improved. The mean NYHA class was reduced by 1.3 (from 2.6 to 1.3).

The mean index of left ventricular end diastolic pressure reduced by 2.11. the mean inter-ventricular septum thickness index was reduced from 8.01 to 6.98 postoperatively. The mean LV posterior wall thickness index was reduced from 7.63 to 6.64. The mean LV mass index was reduced by 31.86 gram (174.15 to 142.3gram; p < 0.0001). The mean ejection fraction was increased by 6.45 from pre to post – operative (54.26 to 60.71, respectively). The mean trans-aortic peak gradient was reduced from 72.12 to 30.8 mmHg.

4. Discussion

Aortic valve replacement (AVR) has become standard therapy for treating diseases of the aortic valve. AVR is now the second most commonly performed cardiac operation and with an increasingly elderly population ,the number of such procedures will inevitably continue to grow [1].

The purpose of aortic valve replacement is to eliminate left ventricular outflow tract obstruction, facilitate regression of left ventricular hypertrophy, and for patients with tight aortic stenosis, to relieve symptoms of heart failure, syncope, angina and sudden death [2]. A regression in left ventricular mass index was documented by many authors [3,4,5].

The postoperative transaortic peak gradient, which is the main cause of concentric hypertrophy and increased left ventricular mass index, decreased dramatically in all patients, with a mean change of 41.36 ± 5.3 mmHg. The more the reduction in transaortic gradient, the more is the improvement in left ventricular functions and mass index.

The electrocardiographic (ECG) score , which reflects cardiac changes from pressure overload, showed a postoperative marked decline in all ECG signs of left ventricular hypertrophy and strain, with a mean decrease of 3 + 0.93 (as in Table 1). This corresponds to results reported by Dare et al., 1993 [6].

Table 1. Mean ECG scores pre and postoperatively

Echocardiography, remains the first choice investigation to evaluate effects of correction of aortic stenosis [7]. However many recent studies showed the superiority of cardiovascular magnetic resonance in certain circumstances [8]. Current study showed improvement in left ventricular systolic and diastolic dimensions and left ventricular mass index. After correction of aortic stenosis, the left ventricular mass index was decreased by > 40 gram which constitutes a reduction of 24% (as shown in Table 2). These data correspond to those reported by De Cario et al., 2003.

Table 2. Mean difference between preoperative and postoperative echo. Data

Knez and others found that the regression in left ventricular hypertrophy after aortic valve replacement was an impact of the improvement in valve orifice area. They also, found that prosthesis-patient mismatch may occur with small-sized valves, although it is uncommon. when it happens, the outcome of surgery will not be satisfactory both in hemodynamics and left ventricular mass regression [9]. The procedure was selected and the prosthesis or the bioprosthesis was selected to keep prosthesis- patient matching as much as possible. Aortic root enlargement procedures were not essential in any of our cases.

When LV mass index was considered as the dependent variable and the other variables were taken as the independent variables, there were significant correlation between that index and the age, New York Heart Association (NYHA) class, valve size, LVED index and LVSD index, jnterventricular septum-thickness, LV posterior wall thickness index, ejection fraction and trans-aortic peak gradient. This means that the patients with higher LV mass index will have higher left ventricular end-diastolic index and LV systoic diamwter index, interventricular septum thickness index, LV posterior wall thickness index, ejection fraction and trans-aortic peak gradient (p < 0.0001).

The mean ejection fraction was increased by 6.45. The effects of correction of aortic valve stenosis were most pronounced among those with a severely reduced ejection fraction before the procedure.

5. Conclusions

Correction of aortic valve stenosis had an improvement in functional status ; systolic and diastolic left ventricular function with a variable degree of regression of left ventricular mass index.

Acknowledgement

Thanks to Dr. Morsi M. Amin who helped us in the statistical analysis.

Competing interests

The authors declare that they have no competing interests.

Authors’ Contributions

H.D.E. did the protocol. took part in surgical operations and follow up, and participated in writing the article. M.E.W. took part in writing the article. M.H.E. took part in surgical operations and follow up, and participated in writing the article, E. E. did the echocardiography and medical follow up.

Abbreviations

LV: left ventricule

NEHA class: New York Heart Association class.

Preop.: preoperative

Postop.: postoperative

LVED index: left ventricular end-diastolic index.

LVSD index: left ventricular systolic diameter index

References

[1]   | Chambers J. Aortic stenosis. BMJ 2005, 330:801-2.
[2]   | Connolly H M, Orszulak TA, Osborn SLand Roger Hodge DO: Aortic vave replacement for aortic stenosiswith severe left ventricular dysfunction; prognostic indicators. Circulation 1997, 95:395-400.
[3]   | Gonzalez-Juanatey JR, Garacia-Acuna JM and Fernandez MV: Influence of the size of aortic valve prostheses on hemodynamics and change in left ventricular mass; implication for surgical management of aortic stenosis. J Thoracic Cardiovascular Surg 1996, 112: 273-80.
[4]   | Sim EK, Orszulak TA, Schaff HV: Influence of prosthesid size on change in left ventricular mass following aortic valve replacement Eur J Cardiothorac Surg 1994, 8: 293-7.
[5]   | Penta de Peppo A, Zeitani J and Nardi P: small functional size after aortic valve replacement; no risk in young to middle-age patients. Ann Thoracic Surg. 2005, 79: 1915-20.
[6]   | Dare AJ, Veinot JP, Edwards WD, Tazelaar HD and Schaff HV: New observation on the etiology of aortic valve disease a surgical pathology study of 236 cases. Hum Pathol. 1993, 24:1330-8.
[7]   | Misawa Y: left ventricular mass index in aortic valve surgery; a new index for early valve replacement. Eur J Cardiothoracic Surg, 24: 667-8.
[8]   | Rajappan K, Bellenger NG, Di Terlizzi M, Yacoub MH, Sheridan DJ and Pennell DJ:Assessment of left ventricular mass regression after aortic valve replacement- cardiovascular magnetic resonance versus M-mode echocardiography. Eur J Cardiothoracic Sur.2003, 24:59-65.
[9]   | Knez I, Maier R, Rehak P and Rigler B: left ventricular architecture after valve replacement due to critical aortic stenosis, an approach to disqualify the myth of valve prosthesis- patient mismatch. Eur. J Cardiothoracic Surg. 2001, 19:797-805.