CLINICAL STUDY: VALVE DISEASE
Coronary flow reserve improves after aortic valve replacement for aortic stenosis: an adenosine transthoracic echocardiography study
David J. R. Hildick-Smith, MA, MRCPa and
Leonard M. Shapiro, MD, FRCP, FACCa
a Cardiac Unit, Papworth Hospital, Cambridge, United Kingdom
Manuscript received October 26, 1999;
revised manuscript received May 8, 2000,
accepted July 10, 2000.
Reprint requests and correspondence: Dr. David Hildick-Smith, Cardiac Unit, Papworth Hospital, Cambridge CB3 8RE, United Kingdom
david.hildick-smith{at}papworth-tr.anglox.nhs.uk
OBJECTIVES
The goal of this study was to assess coronary flow reserve (CFR) before and after aortic valve replacement (AVR).
BACKGROUND
Coronary flow reserve is impaired under conditions of left ventricular (LV) hypertrophy. It is not known whether CFR improves with regression of LV hypertrophy in humans.
METHODS
We investigated 35 patients with pure aortic stenosis, LV hypertrophy and normal coronary arteriograms. Patients underwent adenosine transthoracic echocardiography on two occasions—immediately before AVR and six months postoperatively. Left ventricular mass, distal left anterior descending coronary artery (LAD) diameter, flow and CFR were assessed on each occasion.
RESULTS
Distal LAD diameter was successfully imaged in 30 patients (86%), and blood flow was successfully imaged in 27 (77%). Paired data were subsequently available in 24 patients, of whom 14 were men, mean age 68.1 ± 12.5 years, body mass index 24.5 ± 2.0 kg/m2, aortic valve gradient 93 ± 32 mm Hg. Pre- to post-AVR a significant decrease was seen in LV mass (271 ± 38 vs. 236 ± 32g, p < 0.01) and LV mass index (154 ± 21 vs. 134 ± 21g/m2, p < 0.01). Distal LAD diameter fell from 2.27 ± 0.37 to 2.23 ± 0.35 mm, p = 0.08). Pre- to post-AVR there was no significant change in resting parameters of peak diastolic velocity (0.43 ± 0.16 vs. 0.41 ± 0.11 m/s), distal LAD flow 23.3 ± 10.1 vs. 20.9 ± 5.2 ml/min or distal LAD flow scaled for LV mass (8.7 ± 3.8 vs. 9.0 ± 2.5 ml/min/100 g LV mass), but there was significant increase in hyperemic peak diastolic velocity (0.71 ± 0.26 vs. 1.08 ± 0.24 m/s; p < 0.01), distal LAD flow (37.8 ± 11.3 vs. 53.5 ± 16.1 ml/min; p < 0.01) and distal LAD flow scaled for LV mass (14.3 ± 5.0 vs. 23.3 ± 8.5 ml/min/100 g LV mass; p < 0.01). Coronary flow reserve, therefore, increased from 1.76 ± 0.5 to 2.61 ± 0.7.
CONCLUSIONS
Coronary flow reserve increases after AVR for aortic stenosis. This increase occurs in tandem with regression of LV hypertrophy.
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Abbreviations and Acronyms
| | AVR | = aortic valve replacement | | BMI | = body mass index | | BSA | = body surface area | | CFR | = coronary flow reserve | cos | = cosine incident angle of Doppler beam | | GTN | = glyceryl trinitrate | | IVST | = interventricular septal thickness | | LAD | = left anterior descending coronary artery | | LV | = left ventricle or ventricular | | LVID | = left ventricular internal diameter | | LVMI | = left ventricular mass index | | PWT | = posterior wall thickness | | VTI | = velocity-time integral |
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