title: Natural history of coexistent mitral regurgitation after aortic valve replacement.
abstract: OBJECTIVE
  The long-term evolution of coexistent mitral regurgitation (MR) after aortic valve replacement (AVR) for aortic stenosis remains poorly defined. Prior studies have demonstrated that acute improvement in MR after AVR is modest, and more aggressive approaches have been advocated. This study examines the evolution of MR after AVR and identifies prognostic indicators for MR improvement.
  
  
  METHODS
  We retrospectively evaluated demographic and echocardiographic data of 423 patients who underwent primary isolated AVR for aortic stenosis with coexistent mild (n = 314) or moderate (n = 109) MR at our institution, from 2004 to 2013. For each patient, preoperative and postoperative MR was extracted from 903 echocardiograms and graded on a 0 to 4+ scale. Hierarchic linear models were used to estimate postoperative residual MR over a 5-year follow-up period. Patients were then stratified by improvement in MR, and preoperative risk factors and survival were compared between groups. Cox proportional hazards regression was used to assess the association between survival and preoperative and postoperative MR.
  
  
  RESULTS
  The overall acute reduction in MR was -0.23 degrees per patient. Patients with moderate MR had a -0.53 degree reduction in MR, whereas patients with mild MR had only a -0.13 degree reduction in MR (P < .001). Residual MR, however, worsened over time and regressed back to baseline, particularly in patients with preoperative moderate MR. At last follow-up, 70 (17%) patients returned to 2+ or worse MR. Residual MR at last echocardiographic follow-up was not affected by left ventricular ejection fraction, severity of preoperative aortic valve gradient (AVG), magnitude of reduction of AVG, or other comorbidities. Degree of preoperative MR did not affect midterm survival. Patients whose MR improved after AVR demonstrated a trend toward improved survival (75% vs 65% 5-year survival; P = .06), compared with those without MR whose survival remained unchanged or worsened.
  
  
  CONCLUSIONS
  Coexistent MR modestly improves after AVR, but eventually regresses back to baseline or worsens over time in many patients. Preoperative AVG, reduction of AVG, heart failure, or atrial fibrillation was not predictive of residual MR. Moderate preoperative MR did not adversely affect 5-year survival. Patients with improvement in MR, however, demonstrated a trend toward improved survival at 5 years. More aggressive approaches for coexistent moderate MR should be considered in patients who need AVR for aortic stenosis.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Schubert
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: Leora T
authors.initials: LT
authors.lastname: Yarboro
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: Sushma
authors.initials: S
authors.lastname: Madala
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: Karnika
authors.initials: K
authors.lastname: Ayunipudi
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: Irving L
authors.initials: IL
authors.lastname: Kron
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: John A
authors.initials: JA
authors.lastname: Kern
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: George J
authors.initials: GJ
authors.lastname: Stukenborg
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va. Electronic address: rghanta@virginia.edu.
authors.forename: Ravi K
authors.initials: RK
authors.lastname: Ghanta
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D016009:Chi-Square Distribution; D018450:Disease Progression; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology*; D008944:Mitral Valve Insufficiency / Q000150:complications* / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology; D016016:Proportional Hazards Models; D020127:Recovery of Function; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
keywords: aortic valve; echocardiography; mitral regurgitation; replacement