Aortic Insufficiency with Left Ventricular Dysfunction

Seventeen patients, ages 14-74 years, with severe, isolated aortic insufficiency and reduced ejection fraction (0.25-0.49) underwent aortic valve replacement between January 1973 and July 1977. Three had coronary artery disease and also underwent coronary bypass surgery. By New York Heart Association criteria, one patient was functional class IV, seven were class III, seven were class II and two were class I. Left ventricular (LV) end-diastolic pressure was 19 ± 2 mm Hg (mean ± SEM). LV end-diastolic volume index (218 ± 18 ml/m'), end-systolic volume index (124 ± 11 ml/mi) and LV mass index (240 ± 10 g/m') were increased in all patients. Mean velocity of circumferential fiber shortening (mean Vcf) (0.75 ± 0.05 circ/sec) was depressed in all patients. LV ejection fraction averaged 0.43 i 0.02. There were no operative deaths; one patient had a perioperative myocardial infarction and one developed complete atrioventricular block. Five late deaths occurred, including two patients who were not anticoagulated and died within the first year from severe prosthetic valve obstruction. Actuarially determined 3-year survival is 61 15%. Of the late survivors, six are class I, five are class IX and one is class III. Ten patients who were restudied 14.5 3 months after surgery had satisfactory prosthetic function. In these 10 patients, LV end-diastolic pressure decreased from 16 ± 3 to 10 + 2 mm Hg, LV end-diastolic volume index decreased from 209 + 15 to 155 ± 17 mI/M2, LV end-systolic volume index decreased from 118 ± 10 to 82 ± 14 mI/mn and LV mass decreased from 234 ± 11 to 170 i 16 g/m2. LV volumes returned to normal in only two patients, however, and none had normalization ofLV mass. Ejection fraction increased slightly in the restudied patients (0.43 ± 0.03 to 0.49 0.04; 0.05 < p < 0.10); however, it increased more than 15% in five patients and in four of these it returned to normal. Mean Vcf increased from 0.72 ± 0.08 to 0.95 ± 0.11 cir/sec (p < 0.05), but became normal in only two patients. Our data indicate that aortic valve replacement can be performed with acceptable risk in patients with severe aortic insufficiency and moderately severe impairment of LV function. Functional class was improved or maintained in late survivors, LV systolic pump function improved in 50% of patients, and there was consistent (but usually incomplete) regression of LV dilatation and hypertrophy even in patients who did not improve their ejection fraction.