title: Aortic valve replacement for severe aortic regurgitation in asymptomatic patients with normal ejection fraction and severe left ventricular dilatation.
abstract: OBJECTIVE
  According to current guidelines, aortic valve surgery is a Class II indication for asymptomatic patients with severe aortic regurgitation (AR) accompanied by left ventricular (LV) ejection fraction (LVEF) ≥ 50% and left ventricular end-diastolic dimension (LVEDD) >70 mm. This study aims to assess the postoperative outcomes of asymptomatic patients with severe AR accompanied by LVEF ≥ 50% and LVEDD >70 mm after aortic valve replacement (AVR) and to identify prognostic indicators of the surgery, especially in terms of LV ejection fraction and degree of LV dilatation.
  
  
  METHODS
  We retrospectively identified 192 consecutive asymptomatic patients with severe AR accompanied by LVEF ≥ 50% and LVEDD > 70 mm who underwent isolated AVR from January 2003 to December 2013. Postoperative outcomes and prognostic indicators were evaluated and analysed.
  
  
  RESULTS
  Patients had a mean age of 52.4 ± 16.1 years, and 69.3% were male. The mean LVEF and the mean LVEDD were 58.6 ± 6.6% and 76.0 ± 6.9 mm, respectively. The in-hospital mortality rate was 2.1% and survival rates at 5 and 10 years were 94.5 and 86.6%, respectively. Multivariable analysis indicated that postoperative mortality was associated with age [hazard ratio (HR) 1.059, 95% confidence interval (CI): 1.010-1.125, P = 0.049], preoperative LVEF (HR 0.860 95% CI: 0.748-0.989, P = 0.035) and LVEDD (HR 1.094 95% CI: 1.008-1.188, P = 0.032). Receiver-operating characteristic analysis showed that preoperative LVEF < 55% and LVEDD ≥ 81 mm were the best cut-off values for predicting postoperative mortality. By subgroup analysis, patients with 50 ≤ LVEF < 55% had poorer 5- and 10-year survival rates of 87.4 and 74.8% compared with 97.3% and 91.7% for patients with LVEF ≥ 55% (P = 0.023). Patients with LVEDD ≥ 81 mm had poorer 5- and 10-year survival rates of 85.6 and 72.6% compared with 98.2% and 85.6% for those with LVEDD < 81 mm (P = 0.027).
  
  
  CONCLUSIONS
  AVR can be performed with satisfactory outcomes for severe aortic regurgitation in asymptomatic patients with severe AR accompanied by LVEF ≥ 50% and LVEDD > 70 mm. It is observed that 50% ≤ LVEF < 55% or LVEDD ≥ 81 mm are associated with poorer prognosis in patients undergoing AVR.
authors.affiliation: Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Yin
authors.initials: Y
authors.lastname: Wang
authors.affiliation: Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Jiawei
authors.initials: J
authors.lastname: Shi
authors.affiliation: Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Fei
authors.initials: F
authors.lastname: Li
authors.affiliation: Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Yongjun
authors.initials: Y
authors.lastname: Wang
authors.affiliation: Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China dongnianguo@hotmail.com.
authors.forename: Nianguo
authors.initials: N
authors.lastname: Dong
mesh_terms: D000328:Adult; D000368:Aged; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D019540:Area Under Curve; D058070:Asymptomatic Diseases; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D017379:Hypertrophy, Left Ventricular / Q000150:complications* / Q000401:mortality / Q000503:physiopathology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012372:ROC Curve; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left
keywords: Aortic regurgitation; Aortic valve replacement; Asymptomatic; Left ventricular ejection function; Left ventricular end-diastolic dimension