Summary and Conclusion

Summary
Preoperative left ventricular hypertrophy is a negative factor in
aortic valve replacement. Left ventricular hypertrophy is also a well-
known predictor of morbidity in hypertensive patients. Several studies
have documented the early and late prognostic importance of a
preoperatively increased left ventricular mass index (LVMI). Aortic valve
replacement in patients with aortic stenosis and left ventricular
dysfunction continues to be associated with a high mortality risk despite
surgical and cardiological improvement. Increased left ventricular mass
index (LVMI) could be responsible of higher mortality by means of
contractile impairment, diastolic dysfunction, abnormalities of coronary
flow reserve or cardiac arrhythmias

Our aim was to analyze the effect of increased left ventricular mass
index (LVMI) on early outcomes in patients undergoing aortic valve
replacement due to sever aortic stenosis.

Patients and methods: This study included 339 patients with aortic
stenosis underwent aortic valve replacement in the period from 1998 –
2006 in Mehalla Cardiac Center and National Heart Institute.

Exclusion criteria: Ischemic Heart disease and Co-morbid conditions

(Chronic renal failure, previous cerebro-vascular stroke, Chronic
obstructive pulmonary disease, liver cell failure and AF ).

All patients included in the study were subjected to the following: Full
history taking and complete general and local examination of the heart,
chest and abdomen. 12 leads resting ECG, Laboratory investigations
including: Blood sugar level, lipid profile, kidney and liver function.
Complete echo-Doppler study of the heart for assessment of LV systolic
and diastolic function, calculation of the LV mass Index and assessment
of valves for exclusion.

Echocardiographic study: Preoperative Doppler Echocardiography

was performed in all patients. Normal systolic function was considered if
LVEF >50%. Conversely, systolic dysfunction was defined as LVEF <
50%.

LVMI was calculated by Devereux's formula (Devereux and

Reichek, 1997) considering the diastolic measurements of left ventricular
internal diameter (LVID), interventricular septal thickness (IVST) and
posterior wall thickness (PWT):

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Summary and Conclusion

LVMI (g/m2) = (1.04 [(IVST+LVID+PWT)3–LVID3] – 14 g)/Body

surface area.

According to this formula, LVMI is increased if >134/m2 in men and

>110 g/m2 in women. We have evaluated higher degrees of LVMI and a
new cut-off point was established arbitrarily at the first value of the
superior quartile on the frequency distribution of LVMI values in both
sexes. As we found that all patients with aortic stenosis had increased LV
mass index according to the standard definition we used the criteria of
Rafael et al., (2005) who defined increased LVMI in patients with aortic
stenosis to be 226 g/m2 in males and 216 g/m2 in females. According to
this, 83 patients (47 males and 36 females) had increased LVMI. Patients
with elevated LVMI were older and with lower LVEF.

Results: 83 patients (24.5%) had increased LV mass and 256 patients

(75.5%) had a non-increased LV mass according to the definition of
increased LV mass used in our study as mentioned before. Patients with
increased LV mass had a significantly more severe dyspnoea class and a
more severe angina class (P < 0.001). The prevalence of hypertension,
dyslipidemia, DM and COPD was not significantly different among the
two groups.

Post-operative low cardiac output syndrome occurred in 7 patients

(8.4%) in the group of increased LVMI versus 4 patients (1.6%) in the
group with no increased LVMI and the difference between the two
groups was significant (P < 0.001). shows that post-operative stroke
occurred in 9 patients (10.8%) in the group of increased LVMI versus 11
patients (4.3%) in the group with no increased LVMI and the difference
between the two groups was significant (P < 0.05). The mean duration of
hospital stay was significantly higher in patients with increased LVMI
(12.5 ± 4.5 days vs 10.5 ± 4.5 days for patients with no increased LVMI)
(P < 0.05). The other post-operative morbid conditions as acute renal
failure, respiratory failure, pneumonia, post-operative bleeding and sepsis
was not significantly different in the two groups (P > 0.05).

The overall mortality rate was 7.4% (25/339). The mortality rate in
patients with increased LVMI was significantly higher in patients with
increased LMI (15.7%, 13/83 patients) than patients with no increased
LVMI (4.7%, 12/256 patients (P < 0.001)

The in-hospital mortality in patients with increased LVMI and low

ejection fraction was 31.8% (7/22 patients) and the in-hospital mortality
of patients with increased LVMI and normal ejection fraction was 9.8%
(6/61 patients). The difference between the two groups was significant (P

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Summary and Conclusion

< 0.001). The in-hospital mortality of patients with no increased LVMI

and low EF was 9% (5/45 patients) while it was 3.3% (7/211 patients)
and the difference between patients with no increased LVMI and low EF
and patients with no increase in LVMI and normal EF was significant (P
< 0.05). In all patients, the mortality rate in patients with low EF was
10% (12/67) while it was 4.8% (13/272) in patients with normal EF (P <
0.05).

Univariate analysis of the significant predictors of mortality. PPM

was the most significant predictor of mortality (Odd's ratio 5.6 with 95%
Confidence Interval ranged between 1.31 – 22.3, P < 0.001), then age >
50 years (Odd's ratio 4.5 with 95% Confidence Interval ranged between
2.6 – 17.9, P < 0.001), then CPB time > 120 minutes (Odd's ratio 4.1 with
95% Confidence Interval ranged between 2.7 – 15.7, P < 0.001) and
increased LVMI (Odd's ratio 3.9 with 95% Confidence Interval ranged
between 1.8 – 12.9, P < 0.001).

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Summary and Conclusion

Conclusion
• Increased LVMI is a predictor of poor outcome after aortic
valve replacement.

• Patients with elevated preoperative LVMI have a higher

incidence of morbidity, length of stay and a significant increase in
in-hospital mortality. So, it is mandatory to optimize
cardioprotection and management of these patients to improve
outcomes.

• Patients with elevated preoperative LVMI might benefit of

an earlier surgery in the course of their disease (even in
asymptomatic patients).

• Future prospective and randomized multi-institutional

studies are required to establish LVMI itself like a new parameter
in the timing indication for aortic valve replacement.

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