Author + information
- Received August 5, 2016
- Accepted August 9, 2016
- Published online November 15, 2016.
- Amgad Mentias, MD,
- Ke Feng, MD,
- Alaa Alashi, MD,
- L. Leonardo Rodriguez, MD,
- A. Marc Gillinov, MD,
- Douglas R. Johnston, MD,
- Joseph F. Sabik, MD,
- Lars G. Svensson, MD, PhD,
- Richard A. Grimm, MD,
- Brian P. Griffin, MD and
- Milind Y. Desai, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Milind Y. Desai, Heart and Vascular Institute Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, Ohio 44195.
Background 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.
Objectives 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.
Methods 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.
Results 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/m2 and no AV surgery, the 2 groups of iLVESD <2.5 cm/m2 with AV surgery and iLVESD ≥2.5 cm/m2 with 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.
Conclusions 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.
Dr. Desai is supported in part by Haslam Family Endowed Chair in Cardiovascular Medicine. Dr. Gillinov is a consultant for Edwards Lifesciences, Abbott Vascular, On-X, Medtronic, St. Jude Medical, Abbott, Cryolife, AtriCure, Clearflow, Edwards Lifesciences, and Medtronic; has received research support from St. Jude Medical; and holds equity in Clearflow. Dr. Johnston is a consultant for St. Jude Medical and Edwards Lifesciences. Dr. Sabik is supported by Medtronic; has received research funding from Edwards Lifesciences and Abbott; is a consultant for Medtronic; is a member of the Sorin advisory board; and served as principal investigator for the EXCEL trial. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 5, 2016.
- Accepted August 9, 2016.
- American College of Cardiology Foundation