VALVULAR HEAR7 DISEASE Frequency, Cause and Effect on Operative Outcome of Depressed Left Ventricular Ejection Fraction in Mitral Stenosis Richard W. Snyder II, MD, Richard A. Lange, MD, John E. Willard, MD, D. Brent Glamann, MD, Charles Landau, MD, Brian H. Negus, MD, and L. David Hillis, MD To assess the incidence, pathophysiology and irr fluence on operative outcome of a depressed left ventricular (LV) ejection fraction (EF) in patients with mitral stenosis (MS), demographic, hemody- namic and cineangiographic data on 72 patients (16 men, 56 women, aged 19 to 75 years) with isolated MS were reviewed. Df the 45 who had mi- tral commissurotomy or replacement, operative course and functional class before and after sulc gery were assessed. Df the 72 patients, 21(29%) had an LVEF 20.50. These 21 were similar to the 51 with an LVEF ~0.50 in age, gender, heart rate, intracardiac pressures, transvalvular gradient and valve area, but they had larger LV end-diastolic (79 f 19 [mean -c SD] vs 59 + 15 ml/m*, p ~0.001) and end-systolic volumes (46 + 13 vs 23 -c 6 ml/m*, p <O.OOOl). Df the 45 subjects ub dergoing surgery, operative outcome was similar in the 14 with a depressed and the 31 with a nor mal LVEF. Thus, about 93 of patients with isolated MS have a depressed LVEF. Compared with those with MS and a normal LVEF, these subjeck have hemodynamic derangements of similar severity, but they have larger LV enddiastolic and end-sys tolic volumes, suggesting that impaired LV cow tractile function or excessive afterload (rather than diastolic underfilling), or both, is the cause of a low LVEF. Those with an l.VEF go.50 who UR dergo valve surgery have a similar operative out- come as those with an LVEF ~0.50. (Am J Cardiol1994;73:65-69) From the Deparhnent of Internal Medicine (Cardiovascular Division), University of Texas Southwestern Medical Center, and the Cardiac Catheterization Laboratory, Parkland Memorial Hospital, Dallas, Tex- as. Manuscript received May 24,1993; revised manuscript received and accepted July 7, 1993. Address for reprints: L. David Hillis, MD, Room CS 7.102, Univer- sity of Texas Southwestern Medical Center, 5323 Harry Hines Boule- vard, Dallas, Texas 75235. S everal studies have shown that some patients with isolated rheumatic mitral stenosis (MS) have a depressed left ventricular (LV) ejection fraction (EF),lA but there is uncertainty concerning its etiology. Although some have argued that a depressed LVEF with MS is the result of impaired diastolic iilling (i.e., inad- equate preload),2,7-18 others have suggested that it may be due to depressed LV contractile function3-7J9-22 or excessive LV afterload.2,22 In addition to the continued debate about the pathophysiology of a depressed LVEF in this patient population, there are few published data concerning its tiuence on operative morbidity and mor- tality in those undergoing mitral commissurotomy or valve replacement. The present study was performed to address the following questions: (1) In what percentage of subjects with isolated MS is the LVEF depressed? (2) In these persons, what is the etiology of a depressed LVEF (impaired LV diastolic filling, diminished LV con- tractile function, and/or excessive LV afterload)? (3) Compared with those with MS and a normal LVEF, are those with a depressed EF at increased risk when they undergo mitral commissurotomy or valve replacement? (4) Are those with a depressed LVEF as likely to obtain symptomatic benefit from surgery as those with a nor- mal EF? METHODS Patient population: We reviewed the results of all cardiac catheterizations performed at Parkland Memorial Hospital, Dallas, Texas, from July 1978 to April 1993. Of the 5,505 subjects, we identified all those with iso- lated MS (valve area g2.0 cm2). Patients with any of the following were excluded: (1) moderate or severe mitral regurgitation; (2) moderate or severe aortic stenosis or regurgitation; (3) coronary artery disease (defined as 250% luminal diameter narrowing of a major epicardi- al coronary artery); (4) historical or electrocardiograph- ic evidence of previous myocardial infarction; and (5) a history of any disorder or circumstance possibly associ- ated with LV systolic dysfunction, such as long-stand- ing systemic arterial hypertension or exposure to a known cardiotoxin (i.e., heavy ethanol consumption, cocaine abuse, doxorubicin therapy, or previous medi- astinal irradiation). Seventy-two patients (16 men, 56 women, aged 19 to 75 years) met all entrance criteria and formed the study group. Variables assessed: At catheterization, cardiac out- put was determined in all patients by the Fick principle. MITRAL STENOSIS WITH DEPRESSED LVEF 65