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LV end-systolic dimension predicts mortality in aortic regurgitation
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NEW ORLEANS — Along with symptomatic status, elevated indexed left ventricular end-systolic dimension predicted mortality in patients with moderate to severe or severe aortic regurgitation but no CAD, researchers reported at the American College of Cardiology Scientific Session.
The researchers analyzed 748 patients (mean age, 58 years; 82% men) with moderate to severe or severe aortic regurgitation but no history of MI, CAD or heart surgery to assess whether they benefited from surgery and what characteristics might predict outcomes. The findings were simultaneously published in the Journal of the American College of Cardiology.
“We not uncommonly encounter patients with moderate to severe or severe aortic regurgitation in our clinical practice. However, few contemporary studies exist about them,” Patricia A. Pellikka, MD, professor of medicine and chair of the division of cardiovascular ultrasound at Mayo Clinic, told Cardiology Today. “Current valve guidelines are based on data that are now 10 to 20 years old. During this time, our echo quantitation of valvular heart disease has improved, and so have treatments.”
Among the cohort, 48% had aortic valve surgery and 52% were medically treated.
Among those who had surgery, 93% met guideline criteria, including 79% who had a class I indication for surgery — most of whom were symptomatic — and 14% had a class II indication. Those who had surgery without a class I or II indication requested it, according to the researchers.
During a median 4.9 years of follow-up, 17% of patients died.
After adjustment for age, comorbidities and sex, the determinants of mortality were symptoms and elevated LV end-systolic dimension (P .01 for both), according to the researchers.
Compared with patients with LV end-systolic dimension less than 20 mm/m2, those with LV end-systolic dimension 20 mm/m2 to 25 mm/m2 had elevated risk for mortality (HR = 1.5; 95% CI, 1.01-2.31), as did those with LV end-systolic dimension greater than 25 mm/m2 (HR = 2.2; 95% CI, 1.32-3.77), Pellikka and colleagues found.
“Currently, patients with severe chronic aortic regurgitation are most commonly referred for aortic valve surgery when they have developed cardiac symptoms. According to the guidelines, symptoms are a class I indication for surgery, where the benefit far outweighs the risks,” Pellikka said in an interview. “However, we found that patients referred for aortic valve surgery at an earlier stage had better long-term outcomes. Referring for surgery when the left ventricle has dilated moderately was better than waiting for severe dilatation. Indexing left ventricle dimension for body surface area was also important in establishing the optimal time for intervention, particularly in smaller patients like women and elderly.”
The surgery group had better rates of survival than the medical therapy group (P < .0001), and patients who had a class I indication for surgery had worse postoperative survival compared with those who did not (P < .003), according to the researchers.
“Our data indicate that we should be referring patients based on indexed left ventricular end-systolic dimensions rather than waiting for symptoms,” Pellikka said. “Valve surgery should be considered at an earlier stage of chamber enlargement. Our results about optimal timing of intervention will be important, as percutaneous therapies for intervening on aortic valves continue to evolve.” – by Erik Swain
References:
Yang LT, et al. Abstract 912-04. Presented at: American College of Cardiology Scientific Session; March 16-18, 2019; New Orleans.
Yang LT, et al. J Am Coll Cardiol. 2019;doi:10.1016/j.jacc.2019.01.024.
Disclosures: The authors report no relevant financial disclosures.
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E. Magnus Ohman, MD
How Mayo Clinic treats these patients is very similar to how we do, so the findings were not surprising to me. The key message is that early operations on patients with aortic valve incompetence are beneficial. We tend to think about symptoms and LV dimension in these patients, and this study shows that LV dimension is important, and that you should try to operate prior to symptoms developing.
This study could be helpful toward improving the guidelines. It represents strong, objective evidence from a center of excellence.
This patient population is a particular group that has chronic aortic regurgitation but no coronary disease. The question remains about what to do with patients with aortic regurgitation and concomitant coronary disease, which is typically what we see in clinical practice. This study does not address those patients.
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