Peri-operative changes in diastolic function and outcomes in congenital aortic valve surgery

Abstract

Background: The ratio of early diastolic mitral inflow velocity (E) to early diastolic mitral annular tissue velocity (e'), or E/e', is an echocardiographic measure of left ventricular filling pressure. Peri-operative changes in E/e' and association with outcomes have been demonstrated in adults undergoing surgery for aortic stenosis (AS). We sought to explore changes in E/e' and other diastolic indices in the setting of congenital AS surgery and to assess for association with post-operative outcomes among children and young adults.

Methods: A retrospective, single-center study was performed among patients 6 months to 30 years of age who underwent congenital AS surgery from 2006 to 2018. Tissue Doppler indices were collected from pre- and post-operative echocardiograms. Post-operative outcomes were reviewed.

Results: Sixty-six subjects with subvalvar (45%), valvar (47%), and supravalvar (8%) AS underwent surgery at a median age of 9.5 years (IQR: 4.0-14.8). Pre-operatively, the lateral E/e' ratio was 8.6 (6.7-11.0); 33% had E/e'≥10. Post-operatively, the lateral e' decreased to 9.9 cm/s (8.0-11.4), the E/e' ratio increased to 10.4 (8.3-13.1); and 53% had E/e'≥10 (p-values < 0.0001, 0.0072, and < 0.001, respectively). Pre-operative lateral e' correlated modestly with duration of intubation (ρ = -0.24, p-value 0.048) and post-operative lateral e' correlated modestly with duration of intubation and length of hospital stay (ρ = -0.28 and -0.26, p-values = 0.02 and 0.04, respectively).

Conclusions: Children and young adults who underwent congenital AS surgery had echocardiographic evidence of diastolic dysfunction pre-operatively that worsened post-operatively. Lateral e' may be a sensitive indicator of impaired ventricular relaxation in these patients and may impact duration of intubation and hospital stay.

Keywords: aortic valve; congenital heart disease; congenital heart surgery; echocardiography; left; repair; replacement; ventricle.

FIGURE 1

Peri‐operative change in tissue Doppler indices. The box‐whisker plot demonstrates worsening of the medial and lateral e’ velocities (centimeters/sec) and the lateral E/e’ ratio following congenital aortic valve surgery. E = early diastolic mitral inflow velocity, e’ = early diastolic mitral annular tissue velocity