Echocardiographic Markers of Early Left Ventricular Dysfunction in Asymptomatic Aortic Regurgitation: Is It Time to Change the Guidelines?

Background: The ideal timing for surgery in asymptomatic chronic aortic regurgitation (AR) remains unclear. New thresholds for left ventricular ejection fraction (LVEF), left ventricular (LV) indexed end-systolic volume (iESV), and global longitudinal strain (GLS) have been associated with mortality in these patients. These represent markers of early LV dysfunction.

Objectives: The authors sought to assess the relationship between these markers (LVEF <60%, iESV ≥45 mL/m², and GLS worse than -15%) and mortality, comparing them to Class I/IIa American College of Cardiology/American Heart Association guideline recommendations and absence of any of these.

Methods: A total of 673 asymptomatic patients with chronic clinically significant (≥ moderate-severe) AR between 2004 and 2019 at a single referral center were retrospectively analyzed. The primary study outcome was all-cause mortality.

Results: Mean age was 57 ± 17 years, 97 (14%) were female, 293 (45%) had hypertension, and 273 (41%) had an abnormal number of valve cusps. Aortic valve replacement was performed in 281 (48%) patients, and 69 (10%) died while under surveillance (without aortic valve replacement). LVEF <60% was present in 296 (44%) patients, 122 (25%) of 482 had GLS worse than -15%, and 261 (39%) had iESV ≥45 mL/m². Mortality under surveillance was highest when Class I/IIa recommendations were present (HR: 4.22; 95% CI: 2.15-8.29), followed by the presence of 1 or more markers of early LV dysfunction (HR: 2.18; 95% CI: 1.21-3.92); no markers was used as the reference (all, P < 0.05). LVEF showed the strongest association with mortality, statistically slightly better than GLS and iESV. In the absence of Class I/IIa recommendations, 1 marker of early LV dysfunction was associated with higher, although not statistically significant, mortality compared with no markers (P = 0.063), followed by 2 markers; highest mortality was when all 3 markers were present (HR: 5.46; 95% CI: 2.51-11.90; P < 0.001).

Conclusions: Patients with asymptomatic clinically significant chronic AR incur a survival penalty when Class I/IIa guideline recommendations are attained. In patients without these recommendations, at least 2 markers of early LV dysfunction identify those with higher mortality risk who may benefit from early surgery.