Influence of valve prosthesis type on the recovery of ventricular dysfunction and subendocardial ischaemia following valve replacement for aortic stenosis Julian Collinson a , Marcus Flather a , Andrew J.S. Coats b John R. Pepper c , Michael Henein d, * a Clinical Trials and Evaluation Unit, Royal Brompton and Harefield NHS Trust and National Heart and Lung Institute, London, UK b Department of Cardiology, Royal Brompton and Harefield NHS Trust and National Heart and Lung Institute, London, UK c Department of Cardiac Surgery, Royal Brompton and Harefield NHS Trust and National Heart and Lung Institute, London, UK d Department of Echocardiography, Royal Brompton and Harefield NHS Trust and National Heart and Lung Institute, Sydney Street, London SW3 6NP, UK Received 25 October 2003; received in revised form 28 February 2004; accepted 5 March 2004 Available online 17 July 2004 Abstract Background: Long-standing aortic stenosis (AS) causes significant progressive left ventricular (LV) dysfunction and may result in subendocardial ischaemia. Following aortic valve surgery, LV function may improve and this may be accompanied by reversal of ischaemia. There is debate about the differential effects of valve substitutes. Methods: We studied 33 patients with significant AS and impaired LV systolic function. Patients underwent trans-thoracic Doppler echocardiography and 12-lead electrocardiography pre-operatively, prior to discharge from hospital and at 2.5 (range 1.5–3) years follow-up. Results: Twenty patients received a stentless valve and 13 a stented valve. No patient had significant aortic regurgitation, other valvular disease or coronary artery disease. LV fractional shortening (FS) increased from 19F6% to 26F7% post-operatively and to 33F12% at follow-up in the stentless group ( p b0.001). In the stented group, no significant change was seen in the post-operative FS, although it improved at follow-up and at this point did not differ from the stentless group. LV mass fell from 338F72 to 265F64 g post- operatively and to 170F77 g at follow-up ( p b0.001) in the stentless group, whereas in the stented group a significant fall was seen only at follow-up (329F51 g pre-operatively, 304F68 g post-operatively, 166F28 g at follow-up, p =0.01). LV free wall excursion increased from 0.8F0.3 to 1.1F0.4 cm ( p =0.05) and to 1.4F0.3 cm ( p =0.02 compared with pre-operative values) in the stentless group. In the stented group, values were 1.0F0.4, 1.0F0.3 and 1.3F0.2 cm ( p =0.05 compared with pre-operative) at the three time points, respectively. QRS duration fell from 113F36 ms pre-operatively to 99F12 ms at follow-up in the stentless group and from 117F28 to 99F19 ms in the stented group, p=0.01 for both comparisons. QT interval fell from 385F54 ms pre-operatively to 366F39 ms at follow-up ( p =0.04) in the stentless group with no significant change in the stented group (387F52 and 375F33 ms, p =0.24). There was reversal of LV strain pattern in 11 (55%) of the stentless group and 6 (46%) of the stented group and normalisation of the inverted U wave in two thirds of patients. Conclusion: In patients with AS and severe LV dysfunction, there is a more rapid improvement in LV function following aortic valve replacement with a stentless prosthesis. Improvements in those receiving stented valves appear delayed, although there were no differences between the groups in LV function or mass at follow-up. Normalisation of LV free wall systolic behaviour, narrowing of the QRS complex and a reduction in the QT interval suggest that AS is associated with subendocardial ischaemia that reverses following valve replacement. D 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Aortic stenosis; Left ventricular dysfunction; Myocardial ischaemia 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.03.043 * Corresponding author. Tel.: +44 20 7351 8384; fax: +44 20 7351 8634. E-mail address: m.henein@rbh.nthames.nhs.uk (D.G. Henein). International Journal of Cardiology 97 (2004) 535 – 541 www.elsevier.com/locate/ijcard