Persistence of Reduced Left Ventricular Function after Aortic Valve Surgery for Aortic Valve Regurgitation: Bicuspid versus Tricuspid

Objective: Long-term prognosis of patients with aortic regurgitation (AR) and reduced left ventricular ejection fraction (LVEF) who undergo aortic valve surgery is unknown. Bicuspid aortic valve (BAV) morphotype might be associated with a more severe cardiomyopathy due to the origin as congenital heart disease. We aimed to analyze LVEF recovery after AVR surgery in patients with AR and reduced LVEF at baseline.

Methods: This retrospective analysis included 1170 consecutive patients with moderate to severe AR who underwent aortic valve surgery at our institution between January 2005 and April 2016. Preoperative echocardiography revealed 154 (13%) patients with predominant AR and baseline LVEF < 50%. Follow-up protocol included clinical interview using structured questionnaire and long-term echocardiographic follow-up. A total of 60 (39%) patients had a bicuspid aortic valve (BAV group), while the remaining 94 (61%) patients had a tricuspid morphotype (TAV group).

Results: A total of 154 patients (mean age: 63.5 ± 12.4 years, 71% male) underwent aortic valve surgery for AR in the context of reduced LVEF (mean LVEF 42% ± 8%). Fourteen patients (9%) had severely reduced preoperative LVEF ≤ 30%. Mean EuroSCORE II was 4.62% and mean STS-Score 2.42%, respectively. Follow-up was complete in 129/154 (84%) patients. Mean follow-up was comparable between both study groups (44 ± 39 months versus 38 ± 34 months, p = 0.358, respectively). A total of 21 (16%) patients died during follow-up. Follow-up echocardiography demonstrated similar LVEF recovery in both groups (i.e., LVEF recovered to normal values in 44% BAV patients versus 42% TAV patients, p = 0.577). Multivariate analysis revealed no significant impact of BAV morphotype (i.e., as compared with TAV) on postoperative LVEF recovery (OR 3.4, 95% C.I. 0.6–18.1, p = 0.2). Survival was significant reduced in patients with persisting systolic LV dysfunction versus those in whom LVEF recovered (log rank: p = 0.023).

Conclusion: Our study demonstrates that reduced LVEF persists postoperatively in at least one half of patients who present with aortic regurgitation and reduced LVEF at baseline. Postoperative LVEF recovery is independent of aortic valve morphotype (BAV versus TAV). Postoperative persistence of systolic LV dysfunction is associated with reduced post-AVR survival. Therefore, aortic valve surgery should be considered early before systolic LV dysfunction occurs.