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Aortic valve lesions are often found in patients with rheumatic diseases, but their clinical significance has not been properly evaluated. In the present study, the echocardiographic files of the cardiology unit of the Oulu University Hospital were screened for a diagnosis of aortic insufficiency (AI). The aetiology of the valve disease and specific details of the rheumatic disease were evaluated in 160 patients. Twenty-eight patients (18%) had a history of rheumatic fever. Rheumatic disease was found in 14 patients (8.8%) with AI, which is significantly more than the prevalence of rheumatic diseases (1.8%) in the corresponding age group (35-100 years) in Finland. Rheumatoid arthritis or juvenile rheumatoid arthritis was found in seven patients (4.4%), whereas ankylosing spondylitis or seronegative spondylarthropathy were found in four patients (2.5%). Other rheumatic diseases included Takayasu's arteritis (two patients) and scleroderma (one patient). When 38 patients with pure AI without other possible aetiology were analysed, rheumatic disease was found in five patients (13%). Patients with rheumatic disease as a potential aetiology of AI often had symptomatic valve disease, which required surgical treatment, although great differences between different aetiologies were not found.

Thirty patients with aortic valve incompetence and 21 control subjects were examined by M-mode echocardiography at rest and radionuclide ventriculography during submaximal handgrip exercise. The patients had greater left ventricular dimensions and end-systolic wall stress values but peak systolic wall stress values did not differ. During exercise the controls' ejection fraction increased by 3 +/- 4%, 95% confidence interval (CI) from +1% to +5%, while the aortic incompetence patients showed no change -1% +/- 5%, CI from -3 to +1%. The 15 symptomatic aortic incompetence patients had a different ejection fraction response from the controls (-2 +/- 4%, p less than 0.01), CI from 4% to +1%, but the 15 asymptomatic patients had not (0 +/- 6%, not significant, CI from -3% to +3%). Three symptomatic and two asymptomatic patients with a decrease in ejection fraction below 5% during handgrip were not identified by left ventricular size and function of systolic loading conditions at rest. Neither echocardiographic or radionuclide parameters of left ventricular size and function at rest correlated with the individual ejection fraction changes during handgrip. Thus, in aortic valve incompetence, the radionuclide angiography assessed functional response to handgrip cannot be predicted by left ventricular size and function or systolic loading conditions at rest.

We compared M-mode echocardiographic and gated equilibrium radionuclide angiography assessment of the left ventricular (LV) dimensions at rest and during isometric exercise in 18 patients with chronic aortic valve incompetence. The two methods showed a satisfactory correlation when comparing LV size at rest and during exercise (LV end-diastolic dimension in echocardiography vs LV end-diastolic volume in radionuclide angiography, r = 0.80, P less than 0.01 at rest and r = 0.81, P less than 0.01 at rest and r = 0.75; P less than 0.01 during exercise), but fractional shortening in echocardiography and ejection fraction in radionuclide angiography did not correlate (r = 0.27, not significant (NS) at rest and r = 0.34, NS during exercise). Thus echocardiography and radionuclide angiography describe LV dimensions at rest and during handgrip exercise in a similar fashion, documenting the concordance of these noninvasive methods to describe LV size in aortic incompetence at rest and during exercise.

In order to evaluate the left ventricular response to isometric exercise in different types of aortic valve disease, isometric exercise tests were performed during cardiac catheterization in 14 patients with pure aortic stenosis, 20 with combined aortic stenosis and regurgitation, and 18 with pure aortic regurgitation. Patients with angina pectoris in whom coronary angiography had not been performed were excluded. Thirty-seven patients were recatheterized 12 months after aortic valve replacement, and the ventricular response to exercise was re-evaluated. Preoperatively, the ejection fraction did not change significantly during exercise in patients with aortic stenosis, tended to decrease in patients with combined valve lesion, and decreased significantly in patients with aortic regurgitation (p less than 0.001). In the three patients whose ejection fraction during preoperative exercise decreased to below 0.40, it remained below 0.50 after successful aortic valve replacement. It appears possible to reveal left ventricular dysfunction in many patients with aortic regurgitation and in some with combined aortic valve disease by means of isometric exercise. The severely depressed ventricular dysfunction during exercise does not appear to correct totally after surgery.

Heart catheterization and quantitative left ventricular ciné-angiography data on thirty patients with aortic vlave disease were analyzed pre-operatively and 12 months after insertion of a Björk-Shiley tilting disc valve. The pre-operative and postoperative data were compared and also with a control group of 22 patients with no organic heart disease. According to the functional NYHA classification, 14 patients had improved, 14 were unchanged and 2 had deteriorated. Regurgitation had been totally corrected in 27 patients, and the high or moderate pressure gradient between the left ventricle and aorta had been reduced, but the valve itself caused a gradient of 5 to 35 mmHg. The pre-operatively abnormal pump function, hypertrophy, dilatation and impaired myocardial function had all become markedly more normal. The most obvious changes were an improvement in stroke work relative to end-diastolic volume and myocardial mass (p less than 0.001) and reductions in end-diastolic volume (p less than 0.001), pump power (p less than 0.001) and myocardial mass (p less than 0.001). Aortic valve replacement seems to be an appropriate procedure in cases where the left ventricular performance and haemodynamics are sufficiently disturbed.

To evaluate the possible irreversibility of isometric exercise-induced left ventricular dysfunction in aortic regurgitation, we performed handgrip exercise tests during cardiac catheterization on 17 patients with chronic aortic regurgitation (AR-group), both preoperatively and one year after successful aortic valve replacement. Nine normal subjects served as a control group. Preoperatively, the ejection fraction decreased from 59 +/- 7% to 53 +/- 8% (P less than 0.001) in the AR-group while it remained unchanged in the control group during exercise. A positive correlation existed between the changes in the ejection fraction during pre- and postoperative exercise tests (r = 0.85, P less than 0.001), which revealed that in patients with severely depressed ejection fraction during the preoperative exercise test, the ventricular response to exercise was not totally corrected after surgery. The regression of left ventricular mass was also smaller in the patients with most depressed ventricular response to exercise preoperatively. As the isometric exercise-induced left ventricular dysfunction appears to be partly irreversible, we conclude that the valve replacement should perhaps be performed before stress-induced ventricular dysfunction has occurred. Non-invasive monitoring of ventricular response to exercise might be helpful in optimizing the timing of valve replacement in aortic regurgitation.