Survival in Patients With Severe Aortic Regurgitation and Severe Left Ventricular Dysfunction Is Improved by Aortic Valve Replacement

Abstract

Background-Aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR) and left ventricular (LV) dysfunction entails a higher surgical risk. Though it may improve symptoms and LV size, it is not known whether it translates into a survival benefit. Methods and Results-This retrospective cohort study included patients screened from our echocardiographic database between 1993 and 2007 for patients with severe AR and LV ejection fraction (EF) Յ35%. Charts reviews were conducted for clinical, pharmacological, and surgical information. Mortality data were obtained from the social security death index and analyzed as a function of AVR adjusted for the propensity score. Of the 785 patients with severe AR, 166 patients had severe LV dysfunction defined as an EF Յ35%: 69% of these were men, age 65Ϯ16 years, and LV EF was 23Ϯ8%. Kaplan-Meier analysis revealed that performance of AVR (nϭ53) was associated with a better survival (Pϭ0.001). Adjusted for the propensity score, AVR was associated with a significantly lower mortality hazard (HR 0.59, CI 0.42 to 0.98, Pϭ0.04). Conclusions-There is a clear reluctance to offer AVR in a large number of patients with severe AR associated with LV dysfunction. However, the performance of AVR in these patients is associated with a mortality benefit supporting the current ACC/AHA guidelines. (Circulation. 2009;120[suppl 1]:S134-S138.)

Pre- and Postoperative Predictors of Long-Term Prognosis After Aortic Valve Replacement for Severe Chronic Aortic Regurgitation

“…However, some previous studies showed that the long-term prognosis of patients who underwent AVR was not affected by preoperative LV dysfunction. 25- 27 The mean follow-up period of those previous reports ranged from 3.4 to 4.3 years, which is too short to examine relationships between long-term prognosis and preoperative LV dysfunction. Our data suggested that operation should be performed early before worsening LV function, even if patients are asymptomatic.…”

Aortic Regurgitation With Markedly Reduced Left Ventricular Function Is Not a Contraindication for Aortic Valve Replacement

“…Even modestly decreased LVEF (<55%) in the setting of severe AR has been associated with excess mortality if treated conservatively [14]. Yet patients with severe AR and severe LV dysfunction who undergo AVR have been shown to have better survival than patients treated medically [10]. Clinical practice has been to observe asymptomatic patients with AR only until symptoms or signs of LV dysfunction develop [15].…”

“…Identifying risks for adverse outcomes will guide the treatment options for AVR versus other advanced treatments such as ventricular assist device, cardiac transplantation [9]. Moreover, there are only few reports that AVR offers survival benefit compared with medical therapy for patients with markedly reduced LV function and AR [10]. Therefore, in this study we aimed to (1) assess the perioperative outcomes and mid-term survival on the basis of the patients' LVEF, (2) determine whether patients with markedly reduced LV function can undergo AVR with a reasonable operative risk, and (3) identify risk factors for mid-term survival in patients undergoing AVR with markedly reduced LV function from AR.…”

Prognostic Implications of Mitral Regurgitation in Patients With Severe Aortic Regurgitation

“…1,2 This study was approved by our institutional review board. Our echocardiographic database, which contains records from 1993 to 2007, was searched for patients with severe AR defined by a jet height to left ventricular (LV) outflow tract dimension ratio of Ն0.6 or a prominent holodiastolic flow reversal in the aortic arch or the abdominal aorta.…”