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Myocardial Contractility Impacts Survival Prediction by Symptom Status After Aortic Valve Replacement
Jeffrey Borer1,
Phyllis Supino1, Edmund Herrold1, Clare Hochreiter2, O Isom2, Karl Krieger2, Leonard Girardi2, Nasimullah Khan1, Daniel Santarsieri1.
1SUNY Downstate Medical Center, Brooklyn, NY, USA, 2Weill Cornell Medical Center, New York, NY, USA.

Background: Both preoperative symptoms and poor myocardial contractility individually predict mortality risk among patients (pts) with aortic regurgitation (AR) after aortic valve replacement (AVR). The combined influence of these characteristics on survival is unknown. Methods: We determined pre-AVR symptom status and myocardial contractility among 66 consecutively studied pts with severe AR and subsequent AVR (age 49±15 yrs at AVR, 86% male). Symptom status was defined as New York Heart Association Functional Class (FC). Contractility was calculated as pre-AVR change [α] in LVEF from rest to exercise [ex], adjusted for α in end-systolic wall stress [ESS] from rest to ex [αEF-αESS], using combined echocardiographic and radionuclide cineangiographic data. We related a severe contractility deficit (previously defined, αEF-αESS≥17) and symptom presence (FC 2-4) to late post-AVR survival. Results: During 15 yr followup, 22 pts died (15 of cardiovascular cause). Cox model analysis demonstrated a statistical interaction between severe contractility and symptoms on post AVR death (p=.001[all causes], p=.029 [cardiovascular]). Log rank test comparisons of Kaplan-Meier curves showed that symptomatic patients with severe contractility had ~3 times more likely to die than pts without both descriptors (Figure). Conclusions: In AR, the presence of a severe contractility deficit modulates the prognostic importance of pre-AVR symptoms. Pts with both characteristics are at increased risk for late postoperative death and should be closely monitored after AVR.

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