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Outcomes for Aortic Regurgitation and Preserved LVEF
Study Questions:
What are the outcomes and what is the role for aortic valve intervention among patients with chronic moderate-to-severe (grade 3+) or severe (grade 4+) aortic regurgitation (AR) and preserved left ventricular ejection fraction (LVEF)?
Methods:
In a retrospective, observational study, 1,417 patients (mean age 54 ± 16 years, 75% men) with ≥3+ AR and LVEF ≥50% who were seen and who underwent echocardiography at Cleveland Clinic Foundation between 2002 and 2010 were identified and studied. Clinical data were extracted from medical record review. The primary outcome measure was mortality, as determined by chart review or state and national databases.
Results:
At the time of the initial echocardiogram, 1,228 (87%) patients were asymptomatic; the mean LVEF was 57 ± 4%; 93 (7%) had indexed LV end-systolic dimension (LVESDi) ≥2.5 cm/m2; and the mean Society of Thoracic Score (STS) predicted risk of mortality score was 5.5 ± 8%. At 6.6 ± 3 years, 933 (66%) patients had undergone aortic valve surgery (median interval 55 days [interquartile range 19-435 days] after first echocardiogram; 36% isolated aortic valve surgery, 16% concomitant coronary bypass, and 58% aortic replacement) and 262 (19%) died. The indications for surgery were symptoms (n = 189), asymptomatic LV dilation (LV end-diastolic dimension [LVEDD] ≥6.5 cm, LVESD ≥5 cm, or LVESDi ≥2.5 cm/m2; n =153), concomitant aortic aneurysm (n = 446), or prior treated infective endocarditis (n = 145). In-hospital postoperative mortality was 2% (0.6% in isolated AV surgery). On multivariable Cox survival analysis, compared to the group with LVESDi <2.5 cm/m2 and no aortic valve surgery, the two groups with aortic valve surgery (and either LVESDi <2.5 cm/m2 or LVESDi ≥2.5 cm/m2) were associated with improved survival (hazard ratio 0.62 and 0.42, respectively; both p < 0.01). Survival of patients who underwent aortic valve surgery was similar to the age-/sex-matched US population, with 96% of deaths occurring in those with LVESDi <2.5 cm/m2.
Conclusions:
Among patients with grade ≥3+ AR and preserved LVEF at a high-volume tertiary center, survival was significantly higher among those who underwent aortic valve surgery. The published guideline thresholds for LV dilation were associated with higher mortality risk.
Perspective:
As presented, this study suggests that intervention in asymptomatic patients with grade 3+ or 4+ AR and preserved LVEF should be considered prior to current American Heart Association/American College of Cardiology valvular heart disease guideline thresholds for LV dilation (LVESD >50 mm [Class IIa], LVEDD >65 mm [Class IIb]). However, this was a heterogeneous group with multiple indications for intervention; there was no formal protocol for the systematic monitoring of patients with chronic AR; and selection bias should be anticipated in this retrospective, observational study. Although this study adds some data, it does not solve the dilemma of the optimal timing of intervention for asymptomatic patients with chronic grade 3+ or 4+ AR and normal LVEF.
Keywords: Aortic Valve Insufficiency, Aortic Aneurysm, Cardiac Surgical Procedures, Coronary Artery Bypass, Diagnostic Imaging, Dilatation, Echocardiography, Endocarditis, Heart Valve Diseases, Medical Records, Outcome Assessment, Health Care, Survival, Stroke Volume, Ventricular Function, Left
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