Abnormal exercise hemodynamics in patients with normal systolic function late after aortic valve replacement

We studied the hemodynamic response to supine bicycle exercise in 20 patients late (10 ± 2 years) after aortic valve replacement (for aortic stenosis in 12 patients, aortic insufficiency in six patients, and for combined stenosis and insufficiency in two patients). The pulmonary artery wedge pressure was obtained with a pulmonary balloon catheter, and left ventriculography was performed by digital-subtraction angiography after injection of radiographic contrast into the pulmonary artery. These patients were compared with 11 control subjects with no or minimal cardiac disease studied routinely for evaluation of chest pain in whom left ventricular end-diastolic pressure and a direct contrast ventriculogram were obtained. Compared with the control population, the study population had similar left heart filling pressures (7 ± 3 vs 9 ± 3 mm Hg, NS), but higher left ventricular ejection fractions (75 ± 7% vs 67 ± 7%, p < .02), higher left ventricular muscle mass indexes (106 ± 28 vs 85 ± 9 g/m², p < .01). Elevated myocardial muscle mass led to lower systolic wall stress in the study population than in the control subjects (254 ± 65 vs 320 ± 49 10³·dynes/cm², p < .01) and might explain the higher ejection fraction observed. Fourteen patients had a normal response to exercise (with left heart filling pressures of 16 ± 4 vs 18 ± 2 mm Hg for control subjects, NS; and left ventricular ejection fraction of 77 ± 8% vs 73 ± 5% for control subjects, NS). However, while the remaining six patients had a normal exercise left ventricular ejection fraction (72 ± 9%, NS), they had an abnormal rise in left heart filling pressure (33 ± 8 mm Hg, p < .01). Preoperatively these patients also had higher left ventricular mid- and end-diastolic pressures at similar diastolic volumes, suggesting a decrease in chamber compliance. Thus, late after aortic valve replacement there is a subgroup of patients who, despite normal hemodynamics and normal left ventricular systolic function as assessed by the left ventricular ejection fraction at rest, have an abnormal response to exercise characterized primarily by a substantial rise in left heart filling pressures. Preoperatively this group also has a decrease in diastolic chamber compliance despite nearly normal left ventricular ejection fractions. This abnormality appears to result from a primary derangement of diastolic function that is not evident at rest.