21 by the Wald link specification test).As shown in Figure Figure2,2, the best cut-off value for Vp to predict LV dysfunction was 40 cm/s as it maximized both sensitivity (73%; 95% CI, 55% to 87%) and specificity (96%; 95% CI, 87% to 99%).Figure 2Receiver operating characteristic (ROC) curves assessing the association of transmitral propagation velocities (Vp) with post-cardiopulmonary bypass left ventricular dysfunction (mean and 95% coinfidence limits).The expected mortality of the whole cohort was 22% whereas the observed mortality was only 10.6%. As shown in Table Table4,4, compared with patients without post-CPB LV dysfunction, those experiencing LV dysfunction presented higher in-hospital mortality (18.4% vs. 3.6%, P = 0.044) and an increased incidence of serious cardiac events (81.6 vs. 28.6%, P < 0.001). These patients also required prolonged mechanical ventilation and longer stay in the ICU and in the hospital.Table 4Postoperative clinical outcomeThe incidence of LV dysfunction and cardiac complications increased significantly with the severity of diastolic dysfunction, particularly in patients with a restrictive filling pattern and those with Vp less than 40 cm/s (Figure (Figure3).3). Noteworthy, LV dysfunction was observed in 28 out of 30 patients (90%) with low Vp (��40 cm/sec) as opposed to 7 out of 64 patients with normal-to-high Vp.Figure 3Incidence of post-cardiopulmonary bypass left ventricular dysfunction (black square) and postoperative cardiac complications (open square. Myocardial infarct, arrhythmias and/or low cardiac output syndrome) in relation with the severity of left ventricular ...DiscussionIn this prospective study, 40% of high-risk patients undergoing aortic valve replacement required inotropic support and/or an intraortic balloon pump for weaning from CPB. Advanced age, preoperative LV diastolic dysfunction and prolonged aortic clamping time were identified as independent risk factors of post-CPB LV dysfunction. Among the echocardiographic markers of LV diastolic dysfunction, the transmitral flow propagation wave (Vp) was found superior in terms of prognostic value and reliability. Below a cut-off value of 40 cm/s, 90% of patients required inotropic support after weaning from CPB as opposed to only 11% among those with preoperative Vp >40 cm/s.The anesthetic and surgical techniques were all standardized and protocol-driven hemodynamic treatments were based on information gathered from pressure monitors and TEE examination. In contrast to previous large cohort studies, we focused on aortic valvular patients with an expected operative mortality ��9% based on the Bernstein-Parsonnet algorithm [20].