Effect of pericardial repair after aortic valve replacement on septal and right ventricular function

https://doi.org/10.1016/j.ijcard.2010.10.049Get rights and content

Abstract

Background

Aortic valve replacement (AVR) is associated with reversed septal motion and right ventricular (RV) dysfunction but the cause remains uncertain. The aim of this study was to investigate the role of pericardial repair after AVR on septal and RV function.

Methods

Thirty patients (62 ± 11 years, 18 males) with severe aortic stenosis were studied before and after AVR surgery using echocardiography. Patients were randomly allocated to pericardial repair vs. open pericardium. RV long axis displacement and outflow tract fractional shortening (fs) were measured. RV and right atrial (RA) tissue Doppler and strain rate (SR) were measured as well as RA area. Systolic interventricular septal motion towards and away from the RV was also determined. Stroke volume (SV) was measured by conventional Doppler method. Pre-operative data were compared with those from 30 normal gender and age matched controls.

Results

Post-operatively, global RV ejection function was preserved as shown by SV. However, RV outflow tract fs and long axis displacement both fell (p < 0.01) but not SR. RA area remained unchanged but RA SR fell (p < 0.01). RV displacement correlated with the extent of reversed septal motion (r = 0.60, p < 0.001) as well as RA SR (r = 0.54, p < 0.001). None of the RV or septal measurements was affected by the pericardial repair procedure.

Conclusion

After AVR, septal motion is reversed and correlated directly with RV long axis function. The latter is not affected by pericardial repair but likely related to right atrial surgery injury.

Introduction

Open heart surgery results in reversed septal motion and reduced right ventricular (RV) free wall long axis function [1], [2], [3]. Over the years, a number of potential mechanisms have been proposed to explain such phenomenon including inadequate intra-operative RV myocardial perfusion preservation, right atrial (RA) damage or post-operative epicardial contusion caused by the consistent friction of the RV against the inner sternal surface, in patients left with opened pericardium [1], [4]. None of these potential mechanisms has proved satisfactory enough to alter clinical practice in a way that could preserve RV function. Recently similar findings were interpreted using MRI, in a group of patients who underwent coronary artery bypass graft surgery, on the basis of RV adhesions as a potential mechanism for the restricted tricuspid annular motion and disturbed RV long axis function [5]. On the other hand, other studies have shown recovery of RV function after cardiopulmonary by-pass technique [6], [7].

The aim of this study was therefore to assess in detail the effect of pericardial repair on septal and right ventricular function in a group of patients undergoing isolated aortic valve replacement (AVR) for aortic stenosis. Patients were assessed blinded to their randomization to open or repaired pericardium.

Section snippets

Methods

We studied 30 consecutive symptomatic patients (mean age 62 ± 11 years, 18 males) with severe aortic stenosis based on a peak trans-valvular pressure drop (gradient) ≥ 70 mm Hg and/or aortic valve area < 1.0 cm2 who were referred to the Umeå University Hospital Heart Centre for surgical aortic valve replacement (AVR). Patients were examined the day before, one week after and 6 months after surgery using Doppler echocardiography including tissue Doppler imaging (TDI). All patients had undergone cardiac

Results

Anthropometric data are shown in Table 1. No patient developed significant tricuspid regurgitation or severe pericardial fluid collection after AVR. 11 patients developed atrial fibrillation after AVR but all those were back in sinus rhythm before discharge. Of the 11 patients with atrial fibrillation after AVR, 7 had the pericardial sack closed.

Findings

The findings of this study show that surgical AVR results in significant changes in both left (LV) and right ventricular (RV) function. The interventricular septal motion reversed making it functioning as part of the RV and correlating with RV long axis amplitude. RV systolic long axis amplitude fell as did its free wall systolic and diastolic velocities but in contrast SR was maintained throughout the post-operative period, up to 6 months afterwards. RA SR significantly fell but right heart

Acknowledgements

This study was supported by the Swedish Heart and Lung Foundation, and the Heart Foundation of Northern Sweden. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [20].

References (20)

There are more references available in the full text version of this article.

Cited by (30)

  • Right Ventricular Function After Minimally Invasive Mitral Valve Surgery

    2022, Journal of Cardiothoracic and Vascular Anesthesia
    Citation Excerpt :

    The influence of the pericardium on RV function after cardiac surgery is still unclear, and conflicting results are reported. Lindquist et al20 did not show any differences in the typical TAPSE and RV S’ wave reduction secondary to an open or closed pericardium at the end of surgery. Analog results were reported by Lindstrom et al,21 who found a similar reduction of RV longitudinal function parameters in patients in whom the pericardium was left open versus pericardial closure with a biodegradable patch.

  • Right Ventricular Assessment: Are Regional Longitudinal Measurements of Value?

    2020, Journal of Cardiothoracic and Vascular Anesthesia
  • Perioperative Changes of Right Ventricular Function in Cardiac Surgical Patients Assessed by Myocardial Deformation Analysis and 3-Dimensional Echocardiography

    2020, Journal of Cardiothoracic and Vascular Anesthesia
    Citation Excerpt :

    The discussion, as to whether or not the impairment of the longitudinal contraction of the interventricular septum may contribute to the decreased longitudinal contractility of the RV, remains speculative as well.32 Several authors reported an impairment of the longitudinal contraction of the interventricular septum after cardiac surgery,30,33 whereas a recent study observed that the interventricular septum remained postoperatively unaffected.26 The cause of these controversial findings is unclear.

  • Tricuspid annular plane systolic excursion is significantly reduced during uncomplicated coronary artery bypass surgery: A prospective observational study

    2019, Journal of Thoracic and Cardiovascular Surgery
    Citation Excerpt :

    Chest wall contact impairing RV motion has been observed using magnetic resonance imaging after cardiac surgery.18 This might be evident even when the pericardium is surgically restored, because closing the pericardium has been shown not to alleviate the reduction in RV longitudinal contraction.19 Because a reduction in TAPSE to at least half of normal values seems to be a typical feature of uncomplicated cardiac surgery,27 estimations of RV function after CPB using TAPSE might be problematic.28

View all citing articles on Scopus
View full text