**3. Results and discussion**

As a result of the performed analysis the variables pooled in 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\*, АО\* surface, МО\* surface, MV gradients\*,Еmv, Аmv, Е/А mv), **F8** – coronary blood supply parameters (blood supply type, percentage of coronary artery occlusion (LAD, DB, CA, RCA), number of planned bypass grafting). Indexed parameters, reverse values and second degree were considered in «\*» variables, it has been leading to increase in prognosis efficacy (see Table 2).

Revealing of Initial Factors Defining Results of Operation in

Patients with Aortic Valve Replacement and Coronary Artery Disease 23

coefficient (57)

septum thickness

LV wall thickness

LV wall thickness

LV wall thickness


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 ejection (56) 11 TC\* TC = (EDV-ESV)/(EDD-ESD)\*1/ESV Ventricular wall tensility

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)** 

1 dIVST\* сm Diastolic interventricular

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

5 rdPLVWT\* 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

2 dPLVWT\* сm Diastolic posterior

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


**II Physical parameters (F 2)** 

6 Ketle index\* U Ketle index = 10000\* Weight /Height^2 Ketle index (body weight index) 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

0,61\*Age

7 CO\* l/min CO= SV \* HR / 1000 Cardiac output (blood supply)

9 RPR RPR = TPR /BSA Relative peripheral resistance

10 HI\* U HI =CO /BSA Heart index (109) 11 Asw\* U Asw(LV) = SV\*1,055\*(MBP-5)\*0,0136 LV stroke work (153) 12 LVMW U LVMW = 0,0136 \* 1,055 \*CO \* (MBP-5) LV minute work (157) 13 LVWI LVWI = 0,0136 \* 1,055 \* HI \* (MBP-5) LV work index (160) 14 LVWSI LVWSI = 0,0136 \* 1,055 \* SI \* (MBP-5) LV work stroke index (161) 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)

minute Heart rate

<sup>5</sup>TPR = 79,92\*MBP/CO Total peripheral resistance (59)

Height^0.725 Body surface are<sup>а</sup>

Blood stroke volume by Starr (39)

(110)

№ Variable Unit defenition Variable nomenclature **I Blood supply disturbance (F 1)** 

1 HF I, IIА, IIB, III Heart failure 2 FC I , II, III, IV Functional class

1 Gender 1 - man, 2 – woman Patient gender 2 Age\* years Age 3 Weighr\* kg Weight 4 Height\* cm Height

5 BSA\* m2 BSA= 0.007184 \* Weight^0.423 \*

5 BSV BSV = 90,97 + 0,54 \* PBP - 0,57 \* DBP -

6 HR\* beat per

8 TPR\* dyne\*сm-


Revealing of Initial Factors Defining Results of Operation in

predictor for combined surgeries (Figure2).

0

Fig. 2. Correlation between prognosis and functional class

increase in afterload leads to decrease in LV work efficacy (Figure 3).

1

2

3

4

Patients with Aortic Valve Replacement and Coronary Artery Disease 25

valve functions (F7) (r=0.320 p<0.01), heart parameters (F4) (r=0.261 p<0.05), coronary blood supply parameters (F8) (r=0.046 p<0.05), hemodynamic parameters (F3) (r=0.284 p<0,05), and myocardial function parameters (F5)(r=0.589 p<0.001) have played greater role for peak systolic gradient (PSG). The parameters of the following factors affect changes in LV ejection fraction: heart parameters (F4) (r=0.381 p<0.01), hemodynamic parameters (F3) (r=0.332 p<0.01), coronary blood supply parameters (F8) (r=0.322 p<0.01), and valve function parameters (F7) (r=0.332 p<0.01). The positive surgery prognosis in patients with lower HF (r=-0.111) and lower NYHA FC (II, III) (r=-0.560) was higher than 80%. However, in operated patients with FC IV the surgery prognosis was less than 80%. It was noted that higher FC corresponded to lower LV EF values (r=-0.086). It means that FC IV is a high risk

0 20 40 60 80 100

Physical parameters (F2) suggested that PSG on AV had a trend to increase with age (r=0.264), i.e. compensated processes are progressing depending on age, although general biological and physiological processes are decreasing. However, age had no significant influence on surgery prognosis (r=-0.162). Moderate correlation between prognosis (r>0.31) and peak SPG (r>0,206) was observed when hemodynamic parameters were analyzed (F3). The correlation was direct for prognosis and reverse for SPG: e.g. in patients with CO more than 4.0 l/min surgery prognosis was higher. This parameter increased not due to HR, but due to minute volume (r=-0.215). Such pattern was observed between parameters of LV stroke work (Asw): surgery prognosis was higher if LV Asw was higher (r=0.468). But if SPG was increased, decrease in LV Asw was observed (r=-0.295). It may be concluded that

If peak SPG is more than 60 mmHg, LV Asw becomes less than 100 U, and favorable surgery prognosis does not exceed 80%. If stroke work was more than 100 U, positive surgery prognosis was 80-100%. It means that in patients with coronary artery lesions in combination with aortic defect SPG ≥ 60 mmHg is one of indications for aortic valve replacement. Heart parameters (F4) had the greatest influence on surgery prognosis. Thus,

NYHA FC Prognosis, %


Table 1. Risk factors and variables and their components

We determined that a percentage of complex factor influence on surgery prognosis – peak systolic gradient (PSG) and post-operation ejection fraction dynamics were different (Figure 1).

% influence on the prognosis % influence on the ppgAV % infl

Fig. 1. Percentage of complex factor influence on prognosis, PSG, LVEF in patients suffered from valve defect combined with coronary artery lesions

Thus, heart parameters (F4) (r=0.320 p<0.01),coronary blood supply parameters (F8) (r=0.165 p<0.05), F3 (r=0.330 p<0.01), valve function parameters (F7) (r=0.183 p<0.05), and physical parameters (F2) (r=0.223 p<0.05) had greater influence on prognosis. However,

10 MО s\* cm2 Mitral orifice surface area 11 MV ppg mmHg MV peak pressure gradient 12 MV mpg mmHg MV mean pressure gradient **VIII Coronary blood supply parameters (F8)** 1 CVG 1-right, 2- balanced, 3- left Blood supply type by CVG 2 LAD % Left anterior descending,

3 DB % Diagonal branch, lesion % 4 CA % Circumflex artery, lesion % 5 RCA % Right coronary artery, lesion % 6 IA % Intermediate artery, lesion % 7 No.of grafts pcs Number of grafts

We determined that a percentage of complex factor influence on surgery prognosis – peak systolic gradient (PSG) and post-operation ejection fraction dynamics were different (Figure 1).

**21.6**

**19.1**

% influence on the prognosis % influence on the ppgAV % infl

Fig. 1. Percentage of complex factor influence on prognosis, PSG, LVEF in patients suffered

Thus, heart parameters (F4) (r=0.320 p<0.01),coronary blood supply parameters (F8) (r=0.165 p<0.05), F3 (r=0.330 p<0.01), valve function parameters (F7) (r=0.183 p<0.05), and physical parameters (F2) (r=0.223 p<0.05) had greater influence on prognosis. However,

**16.5**

**16.4**

Table 1. Risk factors and variables and their components

**24.6**

**9.4**

**13.8**

from valve defect combined with coronary artery lesions

**16.5**

**23.9**

**18.9**

**6.1**

**6.1**

**11.2**

**6.6**

**3.1**

**3.4**

**F1**

**F2**

**F3**

**F4**

**F5**

**F6**

**F7**

**F8**

**14.3**

**7**

**10.2**

**19.7**

**5.2**

lesion %

**26.5**

9 Е/А mv U. Е/А mv = Е mv / А mv E/A ratio

valve functions (F7) (r=0.320 p<0.01), heart parameters (F4) (r=0.261 p<0.05), coronary blood supply parameters (F8) (r=0.046 p<0.05), hemodynamic parameters (F3) (r=0.284 p<0,05), and myocardial function parameters (F5)(r=0.589 p<0.001) have played greater role for peak systolic gradient (PSG). The parameters of the following factors affect changes in LV ejection fraction: heart parameters (F4) (r=0.381 p<0.01), hemodynamic parameters (F3) (r=0.332 p<0.01), coronary blood supply parameters (F8) (r=0.322 p<0.01), and valve function parameters (F7) (r=0.332 p<0.01). The positive surgery prognosis in patients with lower HF (r=-0.111) and lower NYHA FC (II, III) (r=-0.560) was higher than 80%. However, in operated patients with FC IV the surgery prognosis was less than 80%. It was noted that higher FC corresponded to lower LV EF values (r=-0.086). It means that FC IV is a high risk predictor for combined surgeries (Figure2).

Fig. 2. Correlation between prognosis and functional class

Physical parameters (F2) suggested that PSG on AV had a trend to increase with age (r=0.264), i.e. compensated processes are progressing depending on age, although general biological and physiological processes are decreasing. However, age had no significant influence on surgery prognosis (r=-0.162). Moderate correlation between prognosis (r>0.31) and peak SPG (r>0,206) was observed when hemodynamic parameters were analyzed (F3). The correlation was direct for prognosis and reverse for SPG: e.g. in patients with CO more than 4.0 l/min surgery prognosis was higher. This parameter increased not due to HR, but due to minute volume (r=-0.215). Such pattern was observed between parameters of LV stroke work (Asw): surgery prognosis was higher if LV Asw was higher (r=0.468). But if SPG was increased, decrease in LV Asw was observed (r=-0.295). It may be concluded that increase in afterload leads to decrease in LV work efficacy (Figure 3).

If peak SPG is more than 60 mmHg, LV Asw becomes less than 100 U, and favorable surgery prognosis does not exceed 80%. If stroke work was more than 100 U, positive surgery prognosis was 80-100%. It means that in patients with coronary artery lesions in combination with aortic defect SPG ≥ 60 mmHg is one of indications for aortic valve replacement. Heart parameters (F4) had the greatest influence on surgery prognosis. Thus,

Revealing of Initial Factors Defining Results of Operation in

Fig. 5. Influence of EDV and ESV on LV ejection fraction

Patients with Aortic Valve Replacement and Coronary Artery Disease 27

20 30 40 50 60 70 80 EDV ESV p/o LV EF,%

30 40 50 60 70 80 EDV p/o ESV p/o p/o LV EF,%

Fig. 6. Influence of p/o EDV and p/o ESV on p/o LV ejection fraction

Fig. 3. Correlation between prognosis with SPG and LV stroke work

Fig. 4. Correlation between SV and SI with surgery outcome

0 20 40 60 80 100

SV SI Prognosis, %

0 20 40 60 80 100 120 140 160 Asw Peak SPG

0 20 40 60 80 100

Fig. 4. Correlation between SV and SI with surgery outcome

A sw Prognosis, %

Fig. 3. Correlation between prognosis with SPG and LV stroke work

Fig. 5. Influence of EDV and ESV on LV ejection fraction

Fig. 6. Influence of p/o EDV and p/o ESV on p/o LV ejection fraction

Revealing of Initial Factors Defining Results of Operation in

numbers of baseline and postoperative LV EF (Figure 8).

30

hibernated myocyte.

40

50

60

70

80

Patients with Aortic Valve Replacement and Coronary Artery Disease 29

LV EF calculated using the program for prognosis significantly correlated with true

30 40 50 60 70

Fig. 8. Correlation of calculated LV EF with pre- and postoperative LV EF

baseline EF p/o EF calculated LV EF,%

Assessment of correlation between postoperative LV EF parameters and calculated ones using the program for surgery prognosis revealed a common pattern (trend lines had

Decrease in postoperative LV EF is caused by cardiopulmonary bypass, aortic occlusion, and cardioplegia through unfavorable influence on myocardial contractility in spite of coronary artery bypass grafting, procedure improving coronary blood supply, activation of

Analysis of myocardial function parameters (F5) showed that surgery prognosis is highly affected by posterior left ventricular wall thickness (PLVWT) (r=-0.306) and to lesser extent by interventricular septum thickness (IVST) (r=-0.072). Increase in IVST leads to greater increase in peak SPG rather than PLVWT (r=0.679 and r=0.526, respectively). It can be possibly explained by appearance of additional component of LV outflow tract obstruction as a hypertrophied IVS. When thickness of IVC and PLVW ranges from 1.5 to 2.0 cm, SPG is equal to 80-120 mmHg, and positive surgery prognosis is 80-100%. However, increased dimensions of IVS and PLVW lead to decrease in percentage of favorable prognosis. Degree of ejection fraction increase was mostly related to PLVWT (r=0.433) than to IVST (r=0.265), had no relation with LV myocardial mass (r=-0.113), although increase in myocardial mass improved surgery prognosis. Thus, optimal left ventricle myocardial mass (LVMM) value

similar direction of dynamics and were approximately at the same level) (Figure 9).

LV parameters had direct correlation with prognosis (r>0.224) and LV EF dynamics (r> 0.598) and reverse correlation with SPG (r<-0.343). LV end-diastolic dimension (EDD) and end-diastolic volume (EDV) had a greater influence on prognosis (r=0.349 and r=0.429, respectively), than LV end-systolic dimension (ESD) and end-systolic volume (ESV) (r=0.303 and r=0.352, respectively). Even in cases when increase in LV EDD (EDV) was observed after surgery and LV ESD (ESV) was constant (or decreased), possibility of favorable surgery prognosis was increased. This relationship between EDV and ESV contributes to increase in stroke volume (SV) and suggests preservation of LV myocardial contraction. The analysis showed that increased SV (r=0.458) and stroke index (SI) (r=0.385) was associated with increased percentage of favorable prognosis. We have found that if SI was >40 ml/m2 (SV=80 ml), positive surgery prognosis was more than 80% (Figure 4).

Analysis of influence of baseline EDV and ESV on postoperative LV EF has shown that this value was greater in patients with preserved LV parameters (Figure 5), and in patients with significant reduction of LV EDV and ESV (Figure 6).

The performed analysis revealed that in patients with normal LV myocardial contractility at baseline we had good prognosis and increased LV EF after surgery. It was determined that if LV EF is higher than 50% at baseline, the positive surgery prognosis exceeds 80%. Such pattern of baseline EDV and ESV influence on LV EF dynamics was observed, if LV EF parameters obtained from calculation using the program for prognosis were analyzed. (Figure 7).

Fig. 7. Influence of baseline EDV and ESV on calculated LV EF

LV parameters had direct correlation with prognosis (r>0.224) and LV EF dynamics (r> 0.598) and reverse correlation with SPG (r<-0.343). LV end-diastolic dimension (EDD) and end-diastolic volume (EDV) had a greater influence on prognosis (r=0.349 and r=0.429, respectively), than LV end-systolic dimension (ESD) and end-systolic volume (ESV) (r=0.303 and r=0.352, respectively). Even in cases when increase in LV EDD (EDV) was observed after surgery and LV ESD (ESV) was constant (or decreased), possibility of favorable surgery prognosis was increased. This relationship between EDV and ESV contributes to increase in stroke volume (SV) and suggests preservation of LV myocardial contraction. The analysis showed that increased SV (r=0.458) and stroke index (SI) (r=0.385) was associated with increased percentage of favorable prognosis. We have found that if SI was >40 ml/m2 (SV=80 ml), positive surgery prognosis was more than

Analysis of influence of baseline EDV and ESV on postoperative LV EF has shown that this value was greater in patients with preserved LV parameters (Figure 5), and in patients with

The performed analysis revealed that in patients with normal LV myocardial contractility at baseline we had good prognosis and increased LV EF after surgery. It was determined that if LV EF is higher than 50% at baseline, the positive surgery prognosis exceeds 80%. Such pattern of baseline EDV and ESV influence on LV EF dynamics was observed, if LV EF parameters obtained from calculation using the program for prognosis were analyzed.

> 30 40 50 60 70 80 EDV ESV calculated LV EF, %

80% (Figure 4).

(Figure 7).

significant reduction of LV EDV and ESV (Figure 6).

0

Fig. 7. Influence of baseline EDV and ESV on calculated LV EF

40

80

120

160

200

240

280

LV EF calculated using the program for prognosis significantly correlated with true numbers of baseline and postoperative LV EF (Figure 8).

Fig. 8. Correlation of calculated LV EF with pre- and postoperative LV EF

Assessment of correlation between postoperative LV EF parameters and calculated ones using the program for surgery prognosis revealed a common pattern (trend lines had similar direction of dynamics and were approximately at the same level) (Figure 9).

Decrease in postoperative LV EF is caused by cardiopulmonary bypass, aortic occlusion, and cardioplegia through unfavorable influence on myocardial contractility in spite of coronary artery bypass grafting, procedure improving coronary blood supply, activation of hibernated myocyte.

Analysis of myocardial function parameters (F5) showed that surgery prognosis is highly affected by posterior left ventricular wall thickness (PLVWT) (r=-0.306) and to lesser extent by interventricular septum thickness (IVST) (r=-0.072). Increase in IVST leads to greater increase in peak SPG rather than PLVWT (r=0.679 and r=0.526, respectively). It can be possibly explained by appearance of additional component of LV outflow tract obstruction as a hypertrophied IVS. When thickness of IVC and PLVW ranges from 1.5 to 2.0 cm, SPG is equal to 80-120 mmHg, and positive surgery prognosis is 80-100%. However, increased dimensions of IVS and PLVW lead to decrease in percentage of favorable prognosis. Degree of ejection fraction increase was mostly related to PLVWT (r=0.433) than to IVST (r=0.265), had no relation with LV myocardial mass (r=-0.113), although increase in myocardial mass improved surgery prognosis. Thus, optimal left ventricle myocardial mass (LVMM) value

Revealing of Initial Factors Defining Results of Operation in

and anterior myocardial infarction prior to surgery.

70%. It allows increasing the favorable surgery percentage.

duration of hospitalization.

**4. Conclusion** 

Patients with Aortic Valve Replacement and Coronary Artery Disease 31

performed in patients with right dominance. Thus, greater number of grafts required corresponds to worse surgery prognosis (r=-0.312). Analysis of coronary artery lesions showed that significance of left descending artery (LAD) lesions, i.e. necessity of its grafting makes worse surgery prognosis (r=-0.303). It was also revealed that there is a direct correlation between grade of LAD lesion and value of mitral regurgitation (r=0.283). This suggests a significant role of LAD in coronary blood supply and it should be grafted if affected, especially in patients with combined lesion of aortic valve and coronary arteries. Our conclusions generally support the literature data. Analysis of the huge body of materials (108 687 aortic valve replacements) performed by Brown et al. in 2009 demonstrated that female gender, age above 70 years and ejection fraction less than 30% led to higher postoperative mortality, higher percentage of postoperative stroke, and prolonged

The authors confirmed the data published by Doenst et al. in 2006 on higher incidence of stroke in women during immediate postoperative period, and did not confirmed the data on a similar percentage of mortality. Although, Doenst et al. (2006) analyzed cases of combined CABG and valve replacement (1567 patients). But this also cannot be a final conclusion (combined interventions have worse results than that of one-organ surgeries). However, Thulin and Sjogren (2000) did not demonstrate any differences in the results of simple aortic valve replacement (121 patients) and valve replacement in combination with CABG (98 patients). Some investigators apart from hemodynamic parameters pay attention on the values of laboratory tests. Thus, Florath et al. (2006) showed that elevated blood levels of glucose, creatine kinase, lactate dehydrogenase, sodium, and proteins in patients prior to aortic valve replacement and CABG (908 patients) resulted in increased postoperative mortality. Jamieson et al. demonstrated results similar to our ones (2003). Bioprosthetic valve replacement and CABG was performed in 1388 patients. The mortality rate in NYHA I-II and NYHA IV was 2% and 16%, respectively. The mortality rate in men and women was 4.6% and 13.8%, respectively. Older patients more often required repeated interventions (59 versus 52 years). Nardi et al (2009) showed that surgery prognosis was worse in patients with low ejection fraction, history of paroxysmal ventricular tachycardia, renal insufficiency,

Patients with aortic valve lesion combined with coronary artery lesion are a severe group for surgical treatment and require intervention at early stages of the disease. NYHA FC IV is a high-risk predictor for combined surgeries CHD + CABG. We believe that systolic gradient ≥60 mmHg in patients assigned to CABG is an indication for combined aortic valve surgery. Analysis of LV linear and volume parameters revealed that LV diastolic dimension and diastolic volume had the greatest influence on prognosis in this patient group. iEDV/iESV ratio with SI>40 ml/ m2 (SV=80 ml) is a good prognostic sign allowing to predict a prognosis of more than 80%. The optimal LVMM value was 350-600 g (200-400 g/m2) in the presence of corresponding linear parameters of LV and IVS, when a surgery prognosis was higher than 80%, and baseline LVEF was more than 50%. Appearance of functional changes in MV (regurgitation grade >1) and TV (regurgitation grade >1) is a poor prognostic factor. LAD grafting in these patients is a required intervention, even is a lesion degree is less than

was 350-600 g (200-400 g/m2) in the presence of corresponding linear parameters of LV and IVS. In these cases, positive surgery prognosis was more than 80%. Increase in ejection fraction more than 50% was postoperatively observed especially in patients with such characteristics. Analysis of valve morphology parameters (F6) revealed that significance of aortic valve calcification increases in peak SPG (r=0.448), but not affecting surgery prognosis (r=0.172). Baseline AV regurgitation also does not influence on surgery outcome (r=0.263). We can see the possible explanation of this fact is that AV calcification in the patients was mostly caused by age-related sclerosis and rheumatoid degeneration with no elements of myocardial inflammation (myocarditis) and inflammation of conduction system.

Fig. 9. Correlation between postoperative EF and calculated LV EF

Decreased ejection fraction was observed in patients who had regurgitation on MV (r=-0.377) and TV (r=-0.313) exceeding Grade I, this also resulted in impairment of surgery prognosis. Analysis of valve function parameters (F7) demonstrated that lower baseline SBG value was associated with more favorable surgery prognosis (r=-0.284). When peak SPG was less than 80 mmHg, favorable surgery prognosis ranged from 90 to 100%. Therefore, in the patients with coronary artery lesions aortic valve replacement should be performed at the early stages of defect manifestations when a systolic gradient is 60-80 mmHg. Analysis of coronary blood supply factor (F8) showed that patients with right dominance had worse surgery prognosis than patients with left dominance. Analysis demonstrated that among patients with right dominance only one artery was grafted in 41.9% patients, and 58.1% patients had two grafted arteries (35.5%) or more (22.6%). However, among patients with left dominance, one artery was grafted in 66.7% patients and only 33.3% patients had two (22.2%) or more (11.1%) grafted arteries, i.e. we see that the larger grafting volume was performed in patients with right dominance. Thus, greater number of grafts required corresponds to worse surgery prognosis (r=-0.312). Analysis of coronary artery lesions showed that significance of left descending artery (LAD) lesions, i.e. necessity of its grafting makes worse surgery prognosis (r=-0.303). It was also revealed that there is a direct correlation between grade of LAD lesion and value of mitral regurgitation (r=0.283). This suggests a significant role of LAD in coronary blood supply and it should be grafted if affected, especially in patients with combined lesion of aortic valve and coronary arteries. Our conclusions generally support the literature data. Analysis of the huge body of materials (108 687 aortic valve replacements) performed by Brown et al. in 2009 demonstrated that female gender, age above 70 years and ejection fraction less than 30% led to higher postoperative mortality, higher percentage of postoperative stroke, and prolonged duration of hospitalization.

The authors confirmed the data published by Doenst et al. in 2006 on higher incidence of stroke in women during immediate postoperative period, and did not confirmed the data on a similar percentage of mortality. Although, Doenst et al. (2006) analyzed cases of combined CABG and valve replacement (1567 patients). But this also cannot be a final conclusion (combined interventions have worse results than that of one-organ surgeries). However, Thulin and Sjogren (2000) did not demonstrate any differences in the results of simple aortic valve replacement (121 patients) and valve replacement in combination with CABG (98 patients). Some investigators apart from hemodynamic parameters pay attention on the values of laboratory tests. Thus, Florath et al. (2006) showed that elevated blood levels of glucose, creatine kinase, lactate dehydrogenase, sodium, and proteins in patients prior to aortic valve replacement and CABG (908 patients) resulted in increased postoperative mortality. Jamieson et al. demonstrated results similar to our ones (2003). Bioprosthetic valve replacement and CABG was performed in 1388 patients. The mortality rate in NYHA I-II and NYHA IV was 2% and 16%, respectively. The mortality rate in men and women was 4.6% and 13.8%, respectively. Older patients more often required repeated interventions (59 versus 52 years). Nardi et al (2009) showed that surgery prognosis was worse in patients with low ejection fraction, history of paroxysmal ventricular tachycardia, renal insufficiency, and anterior myocardial infarction prior to surgery.
