Abstract/Text: OBJECTIVE: Congestive heart failure complicating aortic regurgitation is poorly described, and predictive roles of quantitative versus traditional (symptoms or low ejection fraction) surgical markers are unclear.
METHODS: We prospectively enrolled 287 patients with aortic regurgitation (age, 61 +/- 17 years; 68% male) in whom we performed quantitative Doppler echocardiographic analysis and personal physicians conducted management.
RESULTS: After diagnosis, 40 congestive heart failure episodes occurred under medical management (10-year, 23% +/- 4%) causing high subsequent mortality (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.2-6.8; P = .02). Patients with traditional surgical markers (symptoms or ejection fraction <50%) were surprisingly followed 1.4 +/- 3.3 years under medical management with frequent congestive heart failure (adjusted risk, 4.9; 95% CI, 2.1-11.0; P < .001) and excess postoperative mortality (HR, 3.0; 95% CI, 1.3-7.1; P = .01). Quantitative American Society of Echocardiography aortic regurgitation grading and left ventricular end-systolic volume index independently predicted congestive heart failure (quantitative American Society of Echocardiography severe aortic regurgitation: HR, 3.6; 95% CI, 1.3-13.0; P = .015; end-systolic volume index >or=45 mL/m(2): HR, 2.1; 95% CI, 1.03-4.4; P = .04) or death-congestive heart failure with incremental predictive value (P < .001). Higher congestive heart failure rates occurred with quantitative American Society of Echocardiography severe aortic regurgitation (regurgitant volume of >or=60 mL/beat or orifice of >or=30 mm(2)) versus quantitative American Society of Echocardiography mild aortic regurgitation (10-year: 44% +/- 10% vs 15% +/- 7%, P < .001) and end-systolic volume index of 45 mL/m(2) or greater versus less than 45 mL/m(2) (33% +/- 7% vs 9% +/- 2%, P < .001). Traditional markers (symptoms and ejection fraction <50%) had lower sensitivity for congestive heart failure than quantitative echocardiography (all P < .001). Cardiac surgery for aortic regurgitation markedly reduced congestive heart failure in quantitative American Society of Echocardiography severe aortic regurgitation (HR, 0.23; 95% CI, 0.08-0.68; P = .008) without excess mortality (P = .10).
CONCLUSION: This prospective study of aortic regurgitation shows frequent congestive heart failure under conservative management. Traditional surgical markers (symptoms and ejection fraction <50%) predict subsequent congestive heart failure but are insensitive, and rescue operations are often delayed and associated with excess mortality. Quantitative echocardiography provides congestive heart failure predictors that are independent, incremental, and more sensitive than traditional markers. Cardiac surgery for aortic regurgitation markedly reduces congestive heart failure rates in high-risk patients with aortic regurgitation.

Abstract/Text: BACKGROUND: Indications for valve replacement in patients with aortic regurgitation include diminished ejection fraction and increased left ventricular dimensions. Our objective was to examine the effect of preoperative ejection fraction and left ventricular dimensions on survival and return of normal systolic function (ejection fraction > or = 0.50) after valve replacement for aortic regurgitation.
METHODS: Between 1996 and 2006, 301 patients had aortic valve replacement for moderate or greater chronic aortic regurgitation, and 29% had concomitant replacement of the ascending aorta. We reviewed clinical and echocardiographic variables as well as late vital status.
RESULTS: Patients' mean age was 55.2 +/- 16.5 years, and 78% were male. The mean preoperative ejection fraction was 0.56 +/- 0.12, the mean left ventricular end-systolic dimension was 43 +/- 10 mm, and the mean left ventricular end-diastolic dimension was 63 +/- 9 mm. Operative mortality was 1.7%, and survival at 1, 5, and 10 years was 96%, 90%, and 77%, respectively. This was similar to an age- and sex-matched population (p = 0.214). The level of ejection fraction preoperatively did not predict late survival, nor did absolute values for left ventricular end-systolic dimension and end-diastolic dimension. Indexed left ventricular end-systolic dimension and end-diastolic dimension were predictors (p < 0.01) of late survival. Data from late echocardiography were available for 159 patients (56%) at a mean follow-up of 3.3 +/- 2.6 years. Preoperative ejection fraction, left ventricular end-systolic dimension, indexed end-systolic dimension, end-diastolic dimension, and indexed end-diastolic dimension were univariately predictive of late ejection fraction. In a multivariate model the only predictor of late normal ejection fraction was a higher preoperative ejection fraction (odds ratio, 2.85; p < 0.001).
CONCLUSIONS: In patients who received a valve replacement for aortic regurgitation, decreased ejection fraction and increased left ventricular dimensions were not associated with late mortality. However, larger indexed left ventricular systolic and diastolic dimensions were associated with late mortality. Preservation of late ejection fraction is best if the operation is performed in patients with near normal preoperative left ventricular function.

Abstract/Text: BACKGROUND: Mitral regurgitation (MR) is common in those with severe aortic regurgitation (AR) and can predispose to atrial fibrillation, heart failure, and a need for mitral valve surgery during aortic valve replacement (AVR). However, little data exist as to its clinical and prognostic implications.
METHODS AND RESULTS: Search of our echocardiographic data base between 1993 and 2007 yielded 756 patients with severe AR. with comprehensive clinical data from chart review and mortality data from National Death Index. Mortality was analyzed as a function of MR severity. Effect of AVR and concomitant mitral valve repair were investigated. Patient characteristics were age, 61±17 years; female sex, 41%; and ejection fraction, 54±19%. MR grade ≥2+ was present in 343 (45%) patients: 2+ in 152 (20%), 3+ in 93 (12%), and 4+ in 98 (13%). There was a progressive decrease in survival with each grade of MR (P<0.0001). Performance of AVR was associated with a better survival in those with 3 or 4+ MR (P=0.02). In addition, concomitant mitral valve repair in these patients resulted in a better survival (hazard ratio, 0.29; P=0.02).
CONCLUSIONS: MR is common in patients with severe AR, with 3 or 4+ MR occurring in a quarter of these patients. It is an independent predictor of reduced survival. Performance of AVR and concomitant mitral valve repair is associated with a better survival. Development of MR should serve as an indication for AVR even in asymptomatic patients.

Abstract/Text: BACKGROUND: According to American College of Cardiology/American Heart Association guidelines, isolated aortic valve replacement (AVR) is a class III indication for patients with asymptomatic chronic severe aortic regurgitation (AR), left ventricular (LV) ejection fraction (EF) greater than 50%, LV end-diastolic dimension less than 70 mm, and LV end-systolic dimension less than 50 mm.
METHODS: We screened our echocardiographic database for all chronic severe AR patients between 1993 and 2007. Chart reviews were performed to collect clinical, demographic, and pharmacological data. Mortality was analyzed as a function of AVR.
RESULTS: In all, 123 patients were found to have chronic severe asymptomatic AR; they had a mean age of 60 +/- 17 years and mean LVEF of 60% +/- 15%. A subgroup of 79 patients was found to have asymptomatic severe AR with an LVEF greater than 50%, LV end-diastolic dimension less than 70 mm, and LV end-systolic dimension less than 50 mm. By Kaplan-Meier analysis, patients not undergoing AVR had 1-, 5-, and 10-year survival rates of 86%, 71%, and 46%, respectively, compared with 100%, 94%, and 94%, respectively, for patients who underwent AVR (p = 0.004). Aortic valve replacement remained an independent predictor of increased survival after adjusting for group differences and univariate predictors of mortality. The benefit of AVR was further supported by propensity score analysis.
CONCLUSIONS: Despite serving as a class III indication, AVR is independently associated with increased survival among patients with severe asymptomatic AR, LVEF greater than 50%, LV end-diastolic dimension less than 70 mm, and LV end-systolic dimension less than 50 mm.

2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Abstract/Text: BACKGROUND: Indications for valve replacement in patients with aortic regurgitation include diminished ejection fraction and increased left ventricular dimensions. Our objective was to examine the effect of preoperative ejection fraction and left ventricular dimensions on survival and return of normal systolic function (ejection fraction > or = 0.50) after valve replacement for aortic regurgitation.
METHODS: Between 1996 and 2006, 301 patients had aortic valve replacement for moderate or greater chronic aortic regurgitation, and 29% had concomitant replacement of the ascending aorta. We reviewed clinical and echocardiographic variables as well as late vital status.
RESULTS: Patients' mean age was 55.2 +/- 16.5 years, and 78% were male. The mean preoperative ejection fraction was 0.56 +/- 0.12, the mean left ventricular end-systolic dimension was 43 +/- 10 mm, and the mean left ventricular end-diastolic dimension was 63 +/- 9 mm. Operative mortality was 1.7%, and survival at 1, 5, and 10 years was 96%, 90%, and 77%, respectively. This was similar to an age- and sex-matched population (p = 0.214). The level of ejection fraction preoperatively did not predict late survival, nor did absolute values for left ventricular end-systolic dimension and end-diastolic dimension. Indexed left ventricular end-systolic dimension and end-diastolic dimension were predictors (p < 0.01) of late survival. Data from late echocardiography were available for 159 patients (56%) at a mean follow-up of 3.3 +/- 2.6 years. Preoperative ejection fraction, left ventricular end-systolic dimension, indexed end-systolic dimension, end-diastolic dimension, and indexed end-diastolic dimension were univariately predictive of late ejection fraction. In a multivariate model the only predictor of late normal ejection fraction was a higher preoperative ejection fraction (odds ratio, 2.85; p < 0.001).
CONCLUSIONS: In patients who received a valve replacement for aortic regurgitation, decreased ejection fraction and increased left ventricular dimensions were not associated with late mortality. However, larger indexed left ventricular systolic and diastolic dimensions were associated with late mortality. Preservation of late ejection fraction is best if the operation is performed in patients with near normal preoperative left ventricular function.