Long-Term Outcomes in Patients With Aortic Regurgitation and Preserved Left Ventricular Ejection Fraction

Background: Chronic severe aortic regurgitation (AR) imposes significant volume and pressure overload on the left ventricle (LV), but such patients typically remain in an asymptomatic state for a very long time.

Objectives: This study sought to examine long-term outcomes in a contemporary group of patients with grade III+ chronic AR and preserved left ventricular ejection fraction (LVEF) and the value of aortic valve (AV) surgery on long-term survival. We also wanted to reassess the threshold of LV dimension, beyond which mortality significantly increases.

Methods: The authors studied 1,417 such patients (mean 54 ± 16 years of age, 75% men) seen between 2002 and 2010. Clinical data were obtained and Society of Thoracic Surgeons (STS) score was calculated. The primary endpoint was mortality.

Results: Mean STS score was 5.5% ± 8%, and mean LVEF was 57 ± 4%, whereas 1,228 patients (87%) were asymptomatic, and 93 patients (7%) had indexed LV end-systolic dimension (iLVESD) ≥2.5 cm/m². At 6.6 ± 3 years, 933 patients (66%) underwent AV surgery (36% isolated AV surgery, 16% concomitant coronary bypass, and 58% aortic replacement), and 262 patients (19%) died. In-hospital postoperative mortality was 2% (0.6% in isolated AV surgery). On multivariate Cox survival analysis, compared to the group of iLVESD <2.5 cm/m² and no AV surgery, the 2 groups of iLVESD <2.5 cm/m² with AV surgery and iLVESD ≥2.5 cm/m² with AV surgery were associated with improved survival (hazard ratios: 0.62 and 0.42, respectively; both p < 0.01). Survival of patients who underwent AV surgery was similar to that of an age- and sex-matched U.S. population with 96% of deaths occurring in those with iLVESD <2.5 cm/m².

Conclusions: At a high-volume experienced center, patients with grade III or greater AR and preserved LVEF demonstrated significantly improved long-term survival following AV surgery. The risk of death significantly increased at a lower LV dimension threshold than previously described.