Lower left ventricular end-systolic diameter index (LVESDi) and sex-specific LV end-systolic volume index (LVESVi) thresholds may improve risk stratification of asymptomatic aortic regurgitation (AR), according to a multicenter cohort study published Jan. 21 in JAMA.

At five centers in the Netherlands, Singapore, Hong Kong, Canada and Romania, from December 2003 to December 2022, 808 patients (mean age 56 years, 40% women) with at least moderate-severe AR and preserved LVEF ≥50% were included in the study. Of them, 323 underwent aortic valve surgery (AVS).

Results showed that the mean LVESVi was larger in men than women (39 mL/m² vs. 31 mL/m²; p<0.001), while the mean baseline LVESDi was similar (20 mm/m²; p=0.77).

Over the median follow-up of seven years, for the main outcome of all-cause mortality during medical management, 74 patients died, and researchers report the adjusted six-year survival was lower in women than men (80% vs. 89%; p=0.001). Thresholds associated with mortality were found to be an LVESDi ≥20 mm/m² for women and men, LVESVi ≥40 mL/m² for women and LVESVi ≥45 mL/m² for men.

For the main outcome of all-cause mortality after AVS, survival was similar between women and men (85% vs. 89%; p=0.31). The only parameter associated with mortality was preoperative LVESVi, with a significant sex interaction (hazard ratio, 1.03; 95% CI, 1.00–1.06; p=0.04).

Pilar Lopez Santi, MD, et al., note their current study “demonstrated that preoperative LVESVi sex-specific thresholds were independently associated with postoperative mortality, whereas LVESDi was not.” Furthermore, “LV volumetric dimensions not only better captured sex-related differences in LV remodeling but also provided superior prognostic value during medical management and following AVS,” they write.

In an accompanying editorial comment, Robert O. Bonow, MD, MACC, and Patrick T. O’Gara, MD, MACC, emphasize that these data “identify the importance of sex-based analyses of LV remodeling…” They believe these observations “provide the basis for further work in understanding sex differences in the LV response to chronic volume overload and its clinical aftermath.”