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Eur J Cardiothorac Surg 2003;24:668
© 2003 Elsevier Science NL

Letter to the Editor

Reply to Misawa

Rafael García Fuster*, José A. Montero Argudo, Oscar Gil Albarova, Fernando Hornero Sos, Sergio Cánovas López, Ma José Dalmau Sorlí, María Bueno Codoñer, José A. Buendía Miñano

Universitary General Hospital of Valencia, Valencia, Spain

Received 10 July 2003; accepted 15 July 2003.

* Corresponding author. C/Artes Gráficas no. 4, esc. izq. pta.3., 46010 Valencia, Spain. Tel.: +34-96-3622216
e-mail: rgfuster{at}terra.com

Key Words: Aortic valve replacement • Aortic valve regurgitation • Left ventricular mass index • Left ventricular remodeling

We appreciated the Letter to the Editor by Misawa and we read with great interest their comments on our paper. These authors have reported an interesting study about their experience in a long term echocardiographic follow up performed on patients after aortic valve replacement (AVR) for isolated aortic regurgitation [1]. They concluded that in order to normalize the left ventricular function, those who had left ventricular end-systolic dimension (LVDs) greater than 50 mm and fractional shortening (FS) less than 25% required 3 years after AVR, those patients who had LVDs less than or equal to 50 mm and/or FS greater than or equal to 25%, required only 1 year after AVR. They have shown the delayed hemodynamic recovery in patients with dilated left ventricles.

On the other hand, we studied a group of 614 patients who underwent AVR and we analyzed the effect of increased left ventricular mass index (LVMI) on outcomes. Echocardiographic left ventricular dimensions were used to calculate this measure of ventricular hypertrophy. We evidenced an inhospital adverse outcome and a significantly higher inhospital mortality in patients with increased LVMI. So we suggested that outcomes in asymptomatic patients could be improved before a clinically significant increase in LVMI [2].

The important conclusion of these two studies is that excessive left ventricular hypertrophy or dilatation must be avoided in surgical patients with aortic valve disease in order to reduce inhospital morbimortality and improve long term outcomes after AVR. These patients might benefit of an earlier surgery in the course of their disease (even in asymptomatic phases). As Misawa et al. have said, these studies indicate that operative procedures should be recommended in aortic valve disease patients prior to excessive ventricular remodeling. Therefore it is mandatory to reevaluate the optimal timing for surgical treatment. Marked or excessive left ventricular hypertrophy (>=15 mm) was considered as a class IIb recommendation for AVR in aortic stenosis in the last ACC/AHA Guidelines for the management of patients with valvular heart disease [3]. So, if further studies evidence the usefulness of LVMI in selecting patients for an earlier AVR, this old ventricular hypertrophy parameter might be considered as a novel class IIa recommendation in a future update of these guidelines.

References

  1. Misawa Y., Hasegawa T., Kato M., Horimi H., Yamaguchi T. Serial assessment of left ventricular function after valve replacement for isolated aortic regurgitation. Nippon Kyobu Geka Gakkai Zasshi 1991;39:388-392.[Medline]
  2. García Fuster R., Montero J.A., Gil O., Hornero F., Cánovas S., Dalmau M.J., Bueno M., BuendÍa J.A. Left ventricular mass index in aortic valve surgery: a new index for early valve replacement?. Eur J Cardiothorac Surg 2003;23:696-702.[Abstract/Free Full Text]
  3. Bonow R.O., Carabello B., de León A.C., Jr, Edmunds L.H., Jr, Fedderly B.J., Freed M.D., Gaasdch W.H., McKay C.R., Nishimura R.A., O'Gara P.T., O'Rourke R.A., Rahimtoola S.H. ACC/AHA guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease). J Am Coll Cardiol 1998;32:1458-1486.




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