Left ventricular end-systolic stress-volume index ratio in aortic and mitral regurgitation with normal ejection fraction

Abstract

To evaluate the left ventricular contractile state in regurgitant valvular disease with normal ejection fraction, we analyzed the end-systolic stress-volume index relationship (ESSVR) by means of cineangiography in 15 normal subjects, 11 patients with aortic regurgitation (AR), and 10 patients with mitral regurgitation (MR) whose ejection fraction (EF) was 60% or more. The end-systolic stress-volume index ratio in normal subjects was 5.57 ± 0.60 kdyne/cm⁵/m² (mean ± standard deviation), and we defined the range including ± 2 standard deviations of the ratio as the normal ESSVR range. Six patients with AR and five patients with MR placed inside the normal ESSVR range, termed AR IN and MR IN, but the remaining five patients with AR and MR placed to the right of the normal range, termed AR OUT and MR OUT. EF did not differ between patients with AR IN and AR OUT (69.4 ± 5.4 versus 70.7 ± 6.1%) and between MR IN and MR OUT (71.6 ± 3.6 versus 71.1 ± 7.9%). The EF of the subdivided groups with AR and MR also did not differ from that of normal subjects (70.7 ± 7.3%). This finding showed that the left ventricular contractile state was depressed in patients with AR OUT and MR OUT despite a normal EF. In AR and MR the end-systolic stress and end-systolic volume index of OUT did not differ from those of IN, but the end-diastolic volume index of OUT was larger than that of IN (AR OUT 156.8 ± 27.9 versus AR IN 110.8 ± 24.1 ml/m², MR OUT 160.5 ± 44.7 versus MR IN 101.0 ± 16.6 ml/m²; both p < 0.05), and the regurgitant fraction of OUT was higher than that of IN (AR OUT 52.6 ± 13.6 versus AR IN 29.7 ± 13.3%, MR OUT 52.9 ± 10.2 versus MR IN 30.2 ± 11.4%; both p < 0.05). In addition, there was a linear inverse correlation between the end-systolic stress-volume index ratio and the end-diastolic volume index in all subjects (r = −0.82, n = 36). In normal subjects there was a linear inverse correlation between end-systolic stress and the EF (r = −0.91, n = 15), but this relationship failed to separate patients with OUT from those with IN. Results of the present study suggest that some patients with AR and MR whose EF was normal had a depressed contractile state, and these patients had a large end-diastolic volume index and a high regurgitant fraction. Therefore it may be worthwhile to investigate further the proposition that the end-systolic stress-volume index ratio can provide a more reliable means than the EF of evaluating the preoperative left ventricular contractile state in patients with AR and MR.