title: Long-Term Outcomes in Patients With Aortic Regurgitation and Preserved Left Ventricular Ejection Fraction.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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/m2and no AV surgery, the 2 groups of iLVESD <2.5 cm/m2with AV surgery and iLVESD ≥2.5 cm/m2with 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.
  
  
  
  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.
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Amgad
authors.initials: A
authors.lastname: Mentias
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Ke
authors.initials: K
authors.lastname: Feng
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Alaa
authors.initials: A
authors.lastname: Alashi
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: L Leonardo
authors.initials: LL
authors.lastname: Rodriguez
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Douglas R
authors.initials: DR
authors.lastname: Johnston
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Grimm
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Brian P
authors.initials: BP
authors.lastname: Griffin
authors.affiliation: Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: desaim2@ccf.org.
authors.forename: Milind Y
authors.initials: MY
authors.lastname: Desai
mesh_terms: D001022:Aortic Valve Insufficiency / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D002908:Chronic Disease; D018618:Echocardiography, Doppler, Color; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation; D006352:Heart Ventricles / Q000000981:diagnostic imaging / Q000503:physiopathology*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013318:Stroke Volume / Q000502:physiology*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016277:Ventricular Function, Left / Q000502:physiology*
keywords: aortic valve surgery; indexed left ventricular end-systolic dimension; mortality; outcomes