**3. Results**

140 Aortic Valve Surgery

groups: I group patients with an aortal stenosis and combined aortal defect with prevalence of stenosis (АS) - 165 (41,9 %) patients and II group with aortal insufficiency and combined aortal defect with prevalence of insufficiency (AI) - 229 (58,1 %) patients. The reasons of aortal defect (AD) were: rheumatic disease in 74,8 % of cases, an infectious endocarditis (IE) - 16,3 %, congenital defect АV - 8,5 %, an atherosclerotic degeneration and a calcification - 0,4 %. All patients took chest X-ray, ECG, EchoCG, laboratory examination. Patients condition at baseline was a landmark to determine all totality of defect pathogenetic disorders, and evaluation of the factors affecting the separate components of complete clinical picture creation permitted to consider specially the causes, conditions and

Calculations were performed with the help of «STATISTICA for Windows», v.6.0 and original programs developed in "Excel - 2000" in "Visual Basic for Application" integrated computer language. Group data was divided into numeral and classification ones; additional tables for deviations (abs. and %) of variables from baseline levels were calculated. Difference

of significance was evaluated by χ2criterion and 2x2 tables – by adjusted Fisher test.

1 1 M Xi; S (Xi M)2; m M <sup>1</sup>

*N N* <sup>=</sup> <sup>=</sup> *<sup>N</sup>* = = −= <sup>−</sup> ∑ ∑

Consistency of numerical data with normal distribution law was assessed with help of Kolmogorov test. If the numerical data did not correspond to normal distribution law, nonparametric statistical methods were used - Wilcoxon rank test. Power and direction of correlation between the signs were determined by Pearson correlation coefficient **(r)** and by Spearmanrank correlation, if distribution of the baseline data was deviant. The values of these tests range from -1 to +1. The extreme values are observed in signs associated with linear functional relation. The significance of selected correlation coefficient is assessed by statistics value: r\* *n* − 2 / 1 2 − *r* =ta,f(1). The expression (1) permits to determine *a*, possibility of correlation coefficient difference from zero depending on *r* and sample size *n*. This, in turn, allows comparing the correlation of the same signs in the different sample sizes by possibility. Correlation power was assessed by a value of the correlation coefficient: strong, if r ≥0.7, moderate, if r = 0.3-0.7, weak, ifr<0.3. The differences between compared values were significant if p<0.5, it is consistent with criteria accepted in medical and

Prognosis model is based on the regression analysis. Regression analysis was directed to the test of significance of one (dependent) variable Y from set of other ones, so called independent variables Xj = {X1, X2, … Xp}. The values of the prognostic parameter are defined according to the result of determination of the risk factors based on analysis of the clinical materials. The purpose of linear regression analysis in this study was to predict the values of the resulted variable Y according to the known values of physical parameters, EchoCG parameters and various additional features related to surgery specificity. The index

As a result of these calculations, the model was developed. Based on this model the program was created in "Excel–2000»-« The Program of forecasting of probability of a favorable outcome of surgical treatment of aortal valve defects » (CERTIFICATE SPD RUzbDGU 01377) which helps to calculate a percentage of favorable surgery outcome and dynamics of

of favorable surgery outcome was calculated as an arithmetic mean of risk factors.

LV ejection fraction after surgery with prognostic significance of 75-90%.

*S*

1 1

*i i*

*n n*

Distribution parameters were evaluated by formulas as follows:

consequences of systemic positions.

biological researches.

As a result of the performed analysis the variables put into factor groups (F) affecting the surgery prognosis were determined: F1 – blood supply disturbance (HF, NYHA FC), F2 – physical parameters (gender, age\*, weight\*, height\*, body surface area\*, Ketle index\*, CTI\*), F3 – hemodynamic parameters (SBP\*, DBP\*, MBP\*, BSV, HR\*, BMV\*, TPR\*, SPR, HI\*, LV stroke work\*), F4 – heart parameters (EDD\*, ESD\*, EDV\*, ESV\*, SV\*, EF\*, FS\*, RF\*, SVE\*, RV\*, LA\*, RA\*, PA\*), F5 – myocardial parameters (IVS\*, LVPW\*, LVMM\*, sPLVWT and dPLVWT\*, 2HD\*), F6 –valve morphology (calcification degree on AV, regurgitation degree on AV, MV, and TV), F7- – valve parameters (FA and ascending aorta diameter\*, AV gradients\*, AO\* surface, MO\* surface, MV gradients\*, Emv, Amv, E/A mv). Indexed parameters, reverse values and second degree were considered in «\*» variables, it has been leading to increase in prognosis efficacy (see Table 1).

During research it has been defined, that for patients with isolated АV prosthetics greater influence on the operation forecast was made by factors heart characteristics, the central hemodynamics, indicators of valves, anthopometrical data and myocardium indicators (Fig. 1)

Fig. 1. Share of influence of factors on the forecast


Forecasting of the Possible Outcome of Prosthetics of the Aortal Valve on

11 TC\* TC = (EDV-ESV)/

3 LVMM\* g LVMM = 1,04 \* ((EDD+VST+

1 dIVST\* сm

<sup>4</sup>rsPLVWT

<sup>5</sup>rdPLVWT

Preoperational Anatomo-Functional Hemodynamics and According to Heart Indicators 143

Ventricular wall tensility coefficient (57)

Diastolic interventricular septum thickness

thickness

LV wall thickness

LV wall thickness

№ Variable Unit defenition Variable nomenclature

(EDD-ESD)\*1/ESV

2 dPLVWT\* сm Diastolic posterior LV wall

\* U. rsPLVWT = dPLVWT / EDD Relative systolic posterior

\* U. rdPLVWT = dPLVWT / ESD Relative diastolic posterior

6 2HD\* U. 2HD = (dIVST + dPLVWT)/EDD Relative double thickness

**VI Valve morphology (F 6)**  1 AVca score 1,2,3,4 AV calcification, degree 2 AVreg score 1,2,3,4 AV regurgitation, degree 3 MVreg score 1,2,3,4 MV regurgitation, degree 4 TVreg score 1,2,3,4 TV regurgitation, degree **VII Valve function parameters (F 7)**  1 ARD\* сm Aortic root diameter 2 AAD \* сm Ascending aorta diameter 3 AVppg\* mmHg AV peak pressure gradient 4 AVmpg\* mmHg AV mean pressure gradient 5 AVsfs m/s AV systolic flow speed 6 АО s\* cm2 Aortic orifice surface area

7 Е mv MV E peak 8 А mv MV А peak 9 Е/А mv U. Е/А mv = Е mv / А mv E/A ratio

Table 1. Risk factors and variables and their components

10 MО s\* cm2 Mitral orifice surface area 11 MV ppg mmHg MV peak pressure gradient 12 MV mpg mmHg MV mean pressure gradient

PLVWT)^3 - EDD^3)-13,6 LV myocardial mass

12 RV\* сm Right ventricle 13 LA\* сm Left atrium 14 RA\* сm Right atrium 15 PA\* сm Pulmonary artery 16 PAP mmHg Pulmonary artery pressure 17 PA FAD mm PA fibrous annulus diameter **V Myocardial function parameters (F5)** 


Weight^0.423 \* Height^0.725 Body surface are<sup>а</sup>

Ketle index (body weight index)

Blood stroke volume by Starr (39)

(blood supply)

resistance (59)

resistance (110)

ejection (56)

№ Variable Unit defenition Variable nomenclature

10000\* Weight /Height^2

7 CTI\* % Cardiothoracic index **III Central hemodynamic parameters (F 3)**  1 SBP\* mmHg Systolic blood pressure 2 DBP\* mmHg Diastolic blood pressure 3 MBP\* mmHg MBP = DBP+[(SBP - DBP)/3] Mean blood pressure 4 PBP\* mmHg SBP-DBP Pulse blood pressure

PBP - 0,57 \* DBP - 0,61\*Age

7 CO\* l/min CO= SV \* HR / 1000 Cardiac output

9 RPR RPR = TPR /BSA Relative peripheral

10 HI\* U HI =CO /BSA Heart index (109)

15 HFi HFi= SBP\* HR /LVММ Heart functioning index **IV Heart parameters (F4)**  1 EDD\* сm End-diastolic dimension 2 ESD\* сm End-systolicdimension 3 EDV\* сm3 EDV= 7 \* EDD^3 / (2.4 + EDD) End-diastolic volume 4 ESV\* сm3 ESV = 7 \* ESD^3 / (2.4 + ESD) End-systolic volume 5 SV\* сm3 SV = EDV – ESV Stroke volume 6 SI\* u SI = SV / BSA Stroke index (108) 7 LVEF\* % LVEF = 100\*(EDV-ESV)/EDV Ejection fraction 8 LVFS\* % LVSF = 100\*(EDD-ESD)/EDD Fractional shortening 9 RF % RF = ESV / EDV \* 100 Residual fraction (55) 10 SVE\* % SVE = EDV / ESV \*100 Systolic ventricular

minute Heart rate

5 TPR = 79,92\*MBP/CO Total peripheral

(MBP-5)\*0,0136 LV stroke work (153)

1,055 \*CO \* (MBP-5) LV minute work (157)

1,055 \* HI \* (MBP-5) LV work index (160)

1,055 \* SI \* (MBP-5) LV work stroke index (161)

5 BSA\* m2 BSA= 0.007184 \*

index\* U Ketle index =

5 BSV BSV = 90,97 + 0,54 \*

11 Asw\* U Asw(LV) = SV\*1,055\*

12 LVMW U LVMW = 0,0136 \*

13 LVWI LVWI = 0,0136 \*

14 LVWSI LVWSI = 0,0136 \*

<sup>6</sup>Ketle

6 HR\* beat per

8 TPR\* dyne\*сm-


Table 1. Risk factors and variables and their components

Forecasting of the Possible Outcome of Prosthetics of the Aortal Valve on

after a number of years, leads to increase of AV mpg value.

blood circulation had more accurate operation forecast (Fig. 3).

Fig. 3. Correlation of an indicator with an operation outcome

(r=0,406 and r=0,387 accordingly).

АI (r=0,232), than in a subgroup with АS (r=0,124).

Preoperational Anatomo-Functional Hemodynamics and According to Heart Indicators 145

АS r = 0,612). The loss of aorta elasticity at the expense of sclerotic processes, which occur

The analysis of influence of hemodynamic parameters indicators **(F3)** has shown, that hemodynamic indicators had moderate correlation with the operation forecast (r=0,424). The patients with the big stroke output of blood circulation had the best operation forecast, which means indemnification and adequate regulation of the central hemodynamic. Thus the influence of indicators (F3) on the operation forecast was more in group of patients with

The analysis of influence of heart parameters **(F4)** on the operation forecast has shown that the linear and LV volume indicators have direct correlation with SV and LV EF indicators. The patients with LV sufficient volume indicators at smaller changes on a small circle of

One of the important indicators was the indicator of SV size. The more the SV size was, the more accurate an operation forecast in groups was. SV= (EDV LV - ESV LV) size mostly depends on ESV size, which characterizes the force of cardiac muscle reduction, completeness of LV release. The ESV increase reflects cardiac muscle insufficiency and promotes EDV augmentation in the subsequent cycles. The ESV increase, thus, is one of mechanisms of compensatory reaction realizations at a heart failure, in the form of involvement of Franc-Starling mechanism. Therefore at a stage of preoperative treatment for an adequate estimation of the operation forecast it is necessary to estimate dynamics of the systolic LV size. Reduction of the given indicator during preoperative preparation of patients with the complicated current aortal defect will testify sufficient safety of retractive function and reserve possibilities of a myocardium. The fraction of LV emission influenced the operation forecast in group of patients with АI (r=0,402) more, than in a subgroup with АS (r=0,284), whereas the indicator of fraction of shorting had almost identical influence on the forecast

During the correlation analysis of relation of factors with the operation forecast the following patterns have been revealed.

The moderate force of correlation of blood supply disturbance indicators **(F1)** (r=0,683) with the operation forecast has been revealed. It is accounted for the fact that among the operated patients there were more patients at a serious stage of HF and FC, age-specific patients with the long rheumatic anamnesis complicated with a current aortal defect and acute IE. Thus the bigger dependence of the operation forecast on circulatory unefficiency indicators was in the group of patients with AI (r=0,707), than in the group of patients with АS(r=0,580). The less was НF (r =-0,346) and FC degree on NYHA (r =-0,606), the more favorable there was an operation forecast (Fig. 2).

Fig. 2. Influence of degree HF and FC NYHA on the operation forecast

The analysis of the influence of physical parameters indicators **(F2)** has shown, that the younger the patient was (r =-0,626) and the less Кеtle index (r =-0,324) and CTI (r =-0,584) were, at appropriate height (r=0,385) (that testifies the constitutional maturity of the patient), the more accurate the operation forecast was. Whereas the indicator of body surface had very weak correlation (r =-0,011), that is bound up with the absence of patients with «prosthesis-patient mismatch» in the surveyed group. In hemodynamic groups the correlation was discernible. Dependence of the operation forecast on CTI was shown at patients with АI (r =-0,567) more than at patients with АS (r =-0,298). The great values of indicator CTI shown by radiological signs of a LV arch protrusion on the left side contour and an aortic arch on the right side contour of a heart shade arise and testify the evidence of aortal defect thatis observed at patients who suffer from АV insufficiency. In both groups the patients of the young-age group had more accurate operation forecast. However the influence of an indicator of the body surface area with the forecast was observed more at patients with АS (r=0,363), than at patients with АI (r =-0,184). If to estimate influence of age on peak AV mpg in both groups then the value was higher in the senior age group (АI r = 0,470;

During the correlation analysis of relation of factors with the operation forecast the

The moderate force of correlation of blood supply disturbance indicators **(F1)** (r=0,683) with the operation forecast has been revealed. It is accounted for the fact that among the operated patients there were more patients at a serious stage of HF and FC, age-specific patients with the long rheumatic anamnesis complicated with a current aortal defect and acute IE. Thus the bigger dependence of the operation forecast on circulatory unefficiency indicators was in the group of patients with AI (r=0,707), than in the group of patients with АS(r=0,580). The less was НF (r =-0,346) and FC degree on NYHA (r =-0,606), the more favorable there was an

0 20 40 60 80 100

The analysis of the influence of physical parameters indicators **(F2)** has shown, that the younger the patient was (r =-0,626) and the less Кеtle index (r =-0,324) and CTI (r =-0,584) were, at appropriate height (r=0,385) (that testifies the constitutional maturity of the patient), the more accurate the operation forecast was. Whereas the indicator of body surface had very weak correlation (r =-0,011), that is bound up with the absence of patients with «prosthesis-patient mismatch» in the surveyed group. In hemodynamic groups the correlation was discernible. Dependence of the operation forecast on CTI was shown at patients with АI (r =-0,567) more than at patients with АS (r =-0,298). The great values of indicator CTI shown by radiological signs of a LV arch protrusion on the left side contour and an aortic arch on the right side contour of a heart shade arise and testify the evidence of aortal defect thatis observed at patients who suffer from АV insufficiency. In both groups the patients of the young-age group had more accurate operation forecast. However the influence of an indicator of the body surface area with the forecast was observed more at patients with АS (r=0,363), than at patients with АI (r =-0,184). If to estimate influence of age on peak AV mpg in both groups then the value was higher in the senior age group (АI r = 0,470;

Fig. 2. Influence of degree HF and FC NYHA on the operation forecast

HF NYHA FC Prognosis,%

following patterns have been revealed.

operation forecast (Fig. 2).

0

1

2

3

АS r = 0,612). The loss of aorta elasticity at the expense of sclerotic processes, which occur after a number of years, leads to increase of AV mpg value.

The analysis of influence of hemodynamic parameters indicators **(F3)** has shown, that hemodynamic indicators had moderate correlation with the operation forecast (r=0,424). The patients with the big stroke output of blood circulation had the best operation forecast, which means indemnification and adequate regulation of the central hemodynamic. Thus the influence of indicators (F3) on the operation forecast was more in group of patients with АI (r=0,232), than in a subgroup with АS (r=0,124).

The analysis of influence of heart parameters **(F4)** on the operation forecast has shown that the linear and LV volume indicators have direct correlation with SV and LV EF indicators. The patients with LV sufficient volume indicators at smaller changes on a small circle of blood circulation had more accurate operation forecast (Fig. 3).

Fig. 3. Correlation of an indicator with an operation outcome

One of the important indicators was the indicator of SV size. The more the SV size was, the more accurate an operation forecast in groups was. SV= (EDV LV - ESV LV) size mostly depends on ESV size, which characterizes the force of cardiac muscle reduction, completeness of LV release. The ESV increase reflects cardiac muscle insufficiency and promotes EDV augmentation in the subsequent cycles. The ESV increase, thus, is one of mechanisms of compensatory reaction realizations at a heart failure, in the form of involvement of Franc-Starling mechanism. Therefore at a stage of preoperative treatment for an adequate estimation of the operation forecast it is necessary to estimate dynamics of the systolic LV size. Reduction of the given indicator during preoperative preparation of patients with the complicated current aortal defect will testify sufficient safety of retractive function and reserve possibilities of a myocardium. The fraction of LV emission influenced the operation forecast in group of patients with АI (r=0,402) more, than in a subgroup with АS (r=0,284), whereas the indicator of fraction of shorting had almost identical influence on the forecast (r=0,406 and r=0,387 accordingly).

Forecasting of the Possible Outcome of Prosthetics of the Aortal Valve on

play a great role at expressed LV hypertrophy.

myocardium hypertrophy has development.

of the current post-operative period.

**4. Discussion** 

Preoperational Anatomo-Functional Hemodynamics and According to Heart Indicators 147

It has been revealed, that the expressed hypertrophy carries negative influence on the operation forecast. The low the degree of a hypertrophy of LV walls, IVST and myocardium masses is, the better the operation forecast (Fig. 5). Great values of peak AVmpg (r> 0,663)

Correlation of indicators of myocardial function parameters **(F5)** on the forecast in hemo dynamic groups has shown an identical direction of force of relation, with prevalence of size of correlation factor for group of patients with АS. In case of identical influence of value of LV myocardium mass on the operation forecast in hemodynamic groups (r =-0,407), the degree of hypertrophy IVST (r =-0,459) had more influence on the АS patients' operation forecast, than hypertrophy PLVWT (r =-0,281) did. Whereas the forecast patients with АI have been influenced more by degree of hypertrophy PLVWT (r =-0,323), than hypertrophies IVST (r =-0,131). Evidence of IVST hypertrophy is bad prognostic sign, both at a stenos is of the aortal valve, and at its insufficiency. It is necessary to use surgical treatment of aortal defect at early stages of defect implication, before the expressed

In spite of the fact that all patients had been executed with АV prosthetics, valve morphology variables **(F6)** (a calcification exponent (r =-0,563), regurgitation degree on АV (r = 0,639), changes on MV (r =-0,298) and ТV (r =-0,631)) had high degree of correlation. The expressed calcification and the related to it inflammatory process sometimes with transiting on ARD aortas and surrounding tissues, as a rule, found in patients with АS, leads to the loss of elastic properties and a destruction of elements of an aorta root, making the basic stages of operation more complicated to perform. At times after prosthesis implantation there is a high gradient on a prosthesis which reduces the possibilities of the return LV remodeling and retrogression of myocardium mass. In cases of AV insufficiency (patients with АI), enlarged ARD aortas and the sufficient sizes of LV cavity allow quickly in the conditions of good visibility to implant a larger prosthesis, even bigger than a settled one and to achieve the least transprosthetic gradient of pressure which promotes improvement

Acknowledgement to it was the estimation of the influence of valve function parameters **(F7)** indicators which has shown, that the more the diameter of a root of an aorta is (r = 0,309) and low indicators of initial AV mpg (r =-0,649) are, the more accurate the operation forecast is. So the analysis of group of patients with AS has shown, that the operation forecast among patients with diameter of a fibrous ring more than 2,4 sm, which allowed to implant a prosthesis of adequate diameter without technical complexities, was more accurate. Whereas, in group with AI the operation forecast was more accurate among patients with no more than 3,5cm ARD diameter. Dilatation aorta ARD and expansion of an ascending aorta makes surgeons think about necessity of aortas binding or replacement of ascending department which leads to operation time extension and risk increase. The influence of a systolic gradient of pressure on the forecast has shown, that the higher its reference value is, the worse the operation forecast. If transprosthetic gradient of pressure does not exceed more than 30-40 mmHg in the postoperative period of prosthesis implantation, it allows

achieving a favorable outcome of operation in more than 80 % of cases (Fig. 6).

Revealing of the indicators, which reference values can define the percent of a favorable outcome of operation, prognosticate possible complications, as well as an estimation of

Almost all indicators of myocardial function parameters **(F5)** had average return correlation close to a strong one (r <-0,603) (Fig. 4).

Fig. 4. Correlation of an indicator with the forecast and a systolic gradient of pressure

Fig. 5. Influence of an index of myocardium mass on the operation forecast

It has been revealed, that the expressed hypertrophy carries negative influence on the operation forecast. The low the degree of a hypertrophy of LV walls, IVST and myocardium masses is, the better the operation forecast (Fig. 5). Great values of peak AVmpg (r> 0,663) play a great role at expressed LV hypertrophy.

Correlation of indicators of myocardial function parameters **(F5)** on the forecast in hemo dynamic groups has shown an identical direction of force of relation, with prevalence of size of correlation factor for group of patients with АS. In case of identical influence of value of LV myocardium mass on the operation forecast in hemodynamic groups (r =-0,407), the degree of hypertrophy IVST (r =-0,459) had more influence on the АS patients' operation forecast, than hypertrophy PLVWT (r =-0,281) did. Whereas the forecast patients with АI have been influenced more by degree of hypertrophy PLVWT (r =-0,323), than hypertrophies IVST (r =-0,131). Evidence of IVST hypertrophy is bad prognostic sign, both at a stenos is of the aortal valve, and at its insufficiency. It is necessary to use surgical treatment of aortal defect at early stages of defect implication, before the expressed myocardium hypertrophy has development.

In spite of the fact that all patients had been executed with АV prosthetics, valve morphology variables **(F6)** (a calcification exponent (r =-0,563), regurgitation degree on АV (r = 0,639), changes on MV (r =-0,298) and ТV (r =-0,631)) had high degree of correlation. The expressed calcification and the related to it inflammatory process sometimes with transiting on ARD aortas and surrounding tissues, as a rule, found in patients with АS, leads to the loss of elastic properties and a destruction of elements of an aorta root, making the basic stages of operation more complicated to perform. At times after prosthesis implantation there is a high gradient on a prosthesis which reduces the possibilities of the return LV remodeling and retrogression of myocardium mass. In cases of AV insufficiency (patients with АI), enlarged ARD aortas and the sufficient sizes of LV cavity allow quickly in the conditions of good visibility to implant a larger prosthesis, even bigger than a settled one and to achieve the least transprosthetic gradient of pressure which promotes improvement of the current post-operative period.

Acknowledgement to it was the estimation of the influence of valve function parameters **(F7)** indicators which has shown, that the more the diameter of a root of an aorta is (r = 0,309) and low indicators of initial AV mpg (r =-0,649) are, the more accurate the operation forecast is. So the analysis of group of patients with AS has shown, that the operation forecast among patients with diameter of a fibrous ring more than 2,4 sm, which allowed to implant a prosthesis of adequate diameter without technical complexities, was more accurate. Whereas, in group with AI the operation forecast was more accurate among patients with no more than 3,5cm ARD diameter. Dilatation aorta ARD and expansion of an ascending aorta makes surgeons think about necessity of aortas binding or replacement of ascending department which leads to operation time extension and risk increase. The influence of a systolic gradient of pressure on the forecast has shown, that the higher its reference value is, the worse the operation forecast. If transprosthetic gradient of pressure does not exceed more than 30-40 mmHg in the postoperative period of prosthesis implantation, it allows achieving a favorable outcome of operation in more than 80 % of cases (Fig. 6).
