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Cardiac energetics analysis after aortic valve replacement with 16-mm ATS mechanical valve

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  • Artificial Valve
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Abstract

The 16-mm ATS mechanical valve is one of the smallest prosthetic valves used for aortic valve replacement (AVR) in patients with a very small aortic annulus, and its clinical outcomes are reportedly satisfactory. Here, we analyzed the left ventricular (LV) performance after AVR with the 16-mm ATS mechanical valve, based on the concept of cardiac energetics analysis. Eleven patients who underwent AVR with the 16-mm ATS mechanical valve were enrolled in this study. All underwent echocardiographic examination at three time points: before AVR, approximately 1 month after AVR, and approximately 1 year after AVR. LV contractility (end-systolic elastance [Ees]), afterload (effective arterial elastance [Ea]), and efficiency (ventriculoarterial coupling [Ea/Ees] and the stroke work to pressure–volume area ratio [SW/PVA]) were noninvasively measured by echocardiographic data and blood pressure measurement. Ees transiently decreased after AVR and then recovered to the pre-AVR level at the one-year follow-up. Ea significantly decreased in a stepwise manner. Consequently, Ea/Ees and SW/PVA were also significantly improved at the one-year follow-up compared with those before AVR. The midterm LV performance after AVR with the 16-mm ATS mechanical valve was satisfactory. AVR with the 16-mm ATS mechanical valve is validated as an effective treatment for patients with a very small aortic annulus. The cardiac energetics variables, coupling with the conventional hemodynamic variables, can contribute to a better understanding of the patients’ clinical conditions, and those may serve as promising indices of the cardiac function.

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Conflict of interest

There is no conflict of interest or disclosure for any of the authors with any companies/organizations whose product/services discussed in this manuscript.

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Authors and Affiliations

  1. Department of Cardiovascular Surgery, Aso Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka, 820-8505, Japan

    Tomoki Ushijima, Takayuki Uchida, Sho Matsuyama & Takashi Matsumoto

  2. Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan

    Tomoki Ushijima, Yoshihisa Tanoue & Ryuji Tominaga

Authors
  1. Tomoki Ushijima
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  2. Yoshihisa Tanoue
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  3. Takayuki Uchida
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  4. Sho Matsuyama
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  5. Takashi Matsumoto
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  6. Ryuji Tominaga
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Corresponding authors

Correspondence to Yoshihisa Tanoue or Ryuji Tominaga.

Appendix

Appendix

Theoretical background

The cardiac energetics variables include Ees, Ea, and Ea/Ees and SW/PVA. Ees represents the load-independent index of contractility; Ea represents the index of afterload; and Ea/Ees and SW/PVA are the indices of ventricular efficiency. As particularly described in previous investigations, Ees is the slope of the end-systolic pressure–volume relation [8], and Ea is the ratio of end-systolic pressure to stroke volume [9]. Ea/Ees represents ventriculoarterial coupling between the LV and the arterial system [7]. SW represents the external mechanical work, and PVA represents the total mechanical energy generated by ventricular contraction. The ratio of SW to PVA can be understood as the energy efficiency. These variables are actually determined from the multiple LV pressure–volume loops with a conductance catheter system. Furthermore, SW/PVA can be theoretically predicted by Ees and Ea as follows: SW/PVA = 1/(1 + 0.5 Ea/Ees) [26].

Validity of approximated Ees and Ea

We previously described the approximation methods of Ees and Ea as follows: approximated Ees = mean arterial pressure/minimal ventricular volume; approximated Ea = maximal ventricular pressure/(maximal ventricular volume – minimal ventricular volume) [10]. With this modification, the cardiac energetics variables can be easily calculated.The important point is that end-systolic ventricular volume and end-diastolic ventricular volume according to the pressure–volume loop are not same as minimal ventricular volume and maximal ventricular volume, respectively. Normally, end-systolic ventricular volume is larger than minimal ventricular volume and end-diastolic ventricular volume is lower than maximal ventricular volume. Another important point is that end-systolic ventricular pressure is smaller than maximal ventricular pressure. In these points, the present approximated Ees and Ea are not precisely identical with Ees and Ea measured with a conductance catheter system. In particular, the approximated Ees is calculated not as the ratio of end-systolic pressure to end-systolic ventricular volume, but as the ratio of mean arterial blood pressure to minimal ventricular volume, and therefore, the volume intercept is not defined as zero [15]. The high correlations between Ees and the approximated Ees and between Ea and the approximated Ea were experimentally validated in the basic study using a canine right heart bypass preparation with a conductance catheter system [10]. This modification has the advantages that ventricular volume and blood pressure are measured with the cardiac catheterization, which enables the cardiac energetics analysis in various clinical situations [10–15]. Further modifying this modification in the recent study, the LV performance has been analyzed with the echocardiographic ventricular volume calculation and noninvasively measured blood pressure [16–20]. This modification can be the promising analysis method of ventricular efficiency.

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Ushijima, T., Tanoue, Y., Uchida, T. et al. Cardiac energetics analysis after aortic valve replacement with 16-mm ATS mechanical valve. J Artif Organs 17, 250–257 (2014). https://doi.org/10.1007/s10047-014-0769-x

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  • DOI: https://doi.org/10.1007/s10047-014-0769-x

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