Log in to MyACC
Chronic Aortic Regurgitation Outcomes and Guideline Limitations
Study Questions:
Among patients with significant aortic regurgitation (AR), what are the benefits of aortic valve repair or replacement (AVR), and what is the prognostic value of left ventricular (LV) dimensions?
Methods:
In a large single-center, observational study, clinical data and International Classification of Diseases (ICD)-9 and -10 codes were reviewed for patients who underwent transthoracic echocardiography between January 2006 and October 2017, with evidence of ≥ moderate-severe AR. The study excluded patients with acute aortic dissection, active endocarditis, aortic or mitral stenosis and > mild mitral regurgitation, previous aortic or mitral valve surgery, hypertrophic cardiomyopathy, terminal malignancy, carcinoid heart disease, prior myocardial infarction, prior coronary artery bypass grafting, or coronary artery disease with left main stenosis >50% or two- or three-vessel disease requiring intervention. AR was characterized using an integrated approach of quantitative and semi-quantitative measures. The presence of symptoms was based on retrospective review of the medical record. The 2014 American Heart Association/American College of Cardiology valvular heart disease guidelines were used for comparative threshold for surgical indications. The study endpoint was all-cause mortality derived from national sources.
Results:
Of 748 identified patients (58 ± 17 years of age, 82% men), 387 (52%) were medically treated and 361 (48%) underwent AVR. Of 361 patients who underwent AVR, 334 (93%) met guideline criteria (Class I indications in 284 [79%] patients, including symptoms in 236; and Class II indications in 50 [14%]). The remaining 27 (7%) underwent surgery without a Class I or II indication. At a median follow-up of 4.9 years (interquartile range, 2.3-8.3 years), 125 (17%) patients had died. Age, comorbidities, baseline symptoms, and higher LV end-systolic dimension index (LVESDi) were associated with all-cause mortality (all p < 0.01). Compared to patients with LVESDi <20 mm/m2, those with LVESDi 20-25 mm/m2 (hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.01-2.31), and ≥25 mm/m2 (HR, 2.23; 95% CI, 1.32-3.77) had increased risks of death. AVR was associated with better survival (p < 0.0001). Patients with a Class I indication for surgery had lower postoperative survival (p < 0.003).
Conclusions:
Among patients with ≥ moderate-severe AR, Class I indications for surgery, mainly symptoms, were the most common indications for AVR. Class II indications were associated with better postoperative all-cause mortality. LVESDi was the only LV parameter independently associated with all-cause mortality, and the ideal cutoff appeared to be lower than current guideline recommendations.
Perspective:
This study suggests that the presence of preoperative symptoms among patients with chronic ≥ moderate-severe AR is associated with worse all-cause mortality, and that a threshold lower than the current (Class IIa) LVESDi >25 mm/m2 also might be associated with better outcomes. Other published studies have had similar findings (e.g., de Meester C, et al., JACC Cardiovasc Imaging 2019;12:2880), and some have found prognostic power associated with global longitudinal strain among asymptomatic patients with chronic severe AR and preserved LV ejection fraction (e.g., Alashi A, et al., JACC Cardiovasc Imaging 2018;11:673-82). As was well articulated in a 2011 editorial (Bonow RO, JACC Cardiovasc Imaging 2011;4:231-3), the time may be right to reassess current guideline recommendations for intervention among asymptomatic patients with severe AR and preserved LV ejection fraction.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Aortic Valve Insufficiency, Cardiac Surgical Procedures, Comorbidity, Diagnostic Imaging, Echocardiography, Heart Valve Diseases, Hemodynamics, Outcome Assessment, Health Care, Risk, Stroke Volume, Transcatheter Aortic Valve Replacement
< Back to Listings
