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Exercise radionuclide ventriculography for predicting postoperative left ventricular function in chronic aortic regurgitation
Linköping University, Department of Medicine and Health Sciences, Thoracic Surgery. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Health Sciences, Cardiology. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Health Sciences, Clinical Physiology. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Health Sciences, Thoracic Surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Thoracic and Vascular Surgery.
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2009 (English)In: JACC: Cardiovascular Imaging, ISSN 1936-878X, Vol. 2, no 1, 48-55 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Ejection fraction (EF) reaction upon exercise by radionuclide ventriculography and standard echocardiographic parameters was evaluated as predictors for post-operative left ventricular (LV) function in chronic aortic regurgitation (AR).

Background: The optimal timing of surgery for chronic AR is when the left ventricle is still compensating for the volume and pressure overload without irreversible dysfunction. For asymptomatic patients when EF is normal and LV diameters are borderline, exercise testing is recommended by present guidelines. However, only a limited number of studies have been performed, and data are scarce on this subject.

Methods: Radionuclide ventriculography with multiple gated acquisition at rest and during exercise was performed in 29 consecutive patients with severe chronic aortic regurgitation pre-operatively and 6 months post-operatively. Patient subgroups were formed based on pre-operative EF exercise response (ΔEF) and were categorized as decreasing (ΔEF <−5%), unaltered (−5% ≤ ΔEF ≤ 5%), and increasing (ΔEF > 5%). A 5% or higher increase was considered normal. The LV diameters and mass were measured by echocardiography.

Results: Pre-operative LV diameters were markedly elevated before surgery and diminished significantly after surgery. Left ventricular diameters, LV mass, EF at rest (EFrest), and EF change from rest to exercise (ΔEF) were independent of New York Heart Association functional class. Pre-operative end-diastolic diameter proved to be a predictor for pre- and post-operative ΔEF (p = 0.003; p = 0.04) but not for the nature of the exercise response post-operatively. Patients with decreasing and unaltered EF pre-operatively presented a significantly higher but still abnormal ΔEF post-operatively. Those with increasing EF pre-operatively had a similar response and a normal ΔEF post-operatively. Pre-operative ΔEF was not only a predictor for post-operative ΔEF (p = 0.02) but also classified patients into post-operative subgroups (EF decreasing, p = 0.03; unaltered, p = 0.02; increasing, p = 0.0008).

Conclusions: An abnormal EF response to exercise may also occur in patients who do not fulfill criteria for surgery based on LV dimensions or EF. A follow-up of exercise LV function and adjusting the timing of surgery according to the nature of exercise response could, therefore, be beneficial.

Place, publisher, year, edition, pages
Elsevier , 2009. Vol. 2, no 1, 48-55 p.
Keyword [en]
radionuclide ventriculography, ejection fraction, exercise testing, aortic regurgitation, cardiac surgery
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-13338DOI: 10.1016/j.jcmg.2008.09.009ISI: 000287651900008OAI: oai:DiVA.org:liu-13338DiVA: diva2:18516
Available from: 2008-06-18 Created: 2008-06-18 Last updated: 2011-03-11
In thesis
1. Surgical treatment in chronic aortic regurgitation: Timing, results, prognosis and left ventricular function
Open this publication in new window or tab >>Surgical treatment in chronic aortic regurgitation: Timing, results, prognosis and left ventricular function
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Chronic aortic regurgitation (AR) of varying degree affects 13% of men and 8.5% of women. In persons with severe AR, the expected length of life and its quality are influenced. Some individuals remain asymptomatic for a long period, due to effective compensatory mechanisms, but dysfunction of the left ventricle (LV) usually begins before symptoms appear and can be irreversible by then. This thesis addresses questions of LV function and optimal time for operation of patients suffering from chronic AR. Moreover, detailed echocardiographic studies of the anatomy of the normal aortic valve have been performed to obtain a better understanding of the in vivo anatomic relations within the aortic root.

Patients with chronic AR, without concomitant cardiac disease, were studied both retrospectively (n=88) and prospectively (n=29) and the aortic valves of persons (n=32) free from cardiac disease were investigated.

For the retrospectively studied patients, survival was 82% at 10 years which is an improvement compared with previously published results. The majority of the patients, however, had LV dysfunction preoperatively. By studying patients prospectively by echocardiography, radionuclide ventriculography (MUGA) and cardiopulmonary exercise testing (CPET) our aim was to evaluate the predictive value of measurements of LV function at rest and during exercise for postoperative outcome. LV diameters were markedly elevated prior to and diminished significantly after surgery. Patients with an abnormal exercise ejection fraction (EF) response by MUGA preoperatively, presented the same reaction postoperatively. This could not be predicted by LV function determination at rest, or by NYHA functional class. In spite of median NYHA class II, these patients had a low work capacity on CPET, which was neither improved 6 months postoperatively nor correlated to echocardiographic LV dimensions. Thus, both MUGA and CPET may be useful complements for timing of surgery in patients with chronic AR.

Assuming that patients would benefit from preservation of their native valves the normal aortic valve was studied to gain detailed information about the echocardiographic anatomy and relations within the normal aortic root. This extended examination of the aortic root may facilitate a better planning of aortic valve‐preserving interventions in the future.

Place, publisher, year, edition, pages
Institutionen för medicin och hälsa, 2008. 50 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1069
Keyword
Aortic regurgitation, left ventricular function, exercise, physical capacity, echocardiography
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-12284 (URN)978-91-7393-857-0 (ISBN)
Public defence
2008-09-12, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (English)
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Available from: 2008-06-18 Created: 2008-06-18 Last updated: 2012-05-09

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Tamás, ÉvaBroqvist, MatsOlsson, EvaFranzén, StefanNylander, Eva

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