Original Investigation
Impact of Age and Sex on Left Ventricular Remodeling in Patients With Aortic Regurgitation

https://doi.org/10.1016/j.jacc.2023.02.037Get rights and content

Abstract

Background

Current guidelines for aortic regurgitation (AR) recommend the same linear left ventricular (LV) dimension for intervention regardless of age and sex.

Objectives

The purpose of this study was to evaluate the impact of age and sex on the degree of LV remodeling and outcomes.

Methods

We included consecutive patients with severe AR who were serially monitored by echocardiogram between 2010 and 2016. The 2 main endpoints were as follows: 1) LV end-systolic volume indexed to body surface area (LVESVi) and LV end-diastolic volume indexed to body surface area; and 2) adverse events (AE). We evaluated the longitudinal rate of LV remodeling and determined the association between LV volume and AE by age and sex.

Results

A total of 525 adult patients (26% women) with a median echocardiogram follow-up of 2.0 years (IQR: 1.0-3.6 years) were included. At baseline, older patients (age ≥60 years) had smaller LV volumes compared with younger patients (age <60 years), eg, the mean LVESVi was 27.3 mL/m2 vs 32.3 mL/m2, respectively. Similarly, women had smaller LV volumes compared with men (mean LVESVi was 23.3 mL/m2 vs 32.4 mL/m2). On serial evaluation, older patients and women maintained smaller LV volumes compared with younger patients and men, respectively. There were 210 (40%) AE during follow-up. The optimal discriminatory threshold for AE varies by age and sex, eg, the LVESVi threshold was highest for young men (50 mL/m2), intermediate for older men (35 mL/m2), and lowest for women (27 mL/m2).

Conclusions

On serial evaluation, older patients and women with chronic AR maintained smaller LV volumes than younger patients and men, respectively, and develop AE at lower LV volumes.

Section snippets

Study population

The study cohort consisted of patients on routine surveillance for chronic AR with serial echocardiograms at the Cleveland Clinic (Supplemental Figure 1). We included consecutive patients of at least 21 years of age with moderate to severe AR or severe AR and LV ejection fraction ≥50% who underwent echocardiographic studies between 2010 and 2016 at baseline and at least 1 follow-up study that is ≥6 months from the baseline. Patients aged <21 years were excluded to limit the inclusion of

Results

The study included 525 patients with 1,687 echocardiograms showing moderate to severe or severe AR over a median follow-up of 2.0 years (IQR: 1.0-3.6 years). At baseline examination, the mean age was 55.9 ± 15.7 years, and 25.7% were women. The patients were either asymptomatic (74.7%) or with only minimal symptoms (25.3%) (stage C valvular heart disease). The most common etiology of AR was bicuspid AV (26.7%), and this occurred predominantly among the younger cohort (37.7%) and men (33.6%).

Discussion

In this cohort of patients with moderate to severe or severe AR and preserved LV systolic function, we showed that despite indexing to BSA, LV volumes were smaller in older compared with younger patients, and in women compared with men. These differences in LV volumes persist on serial assessment over time. In addition, LV volumetric assessment was a better prognostic parameter than linear dimension. The optimal discriminatory volume thresholds above which the rate of adverse events

Conclusions

Independent of BSA, older patients and women with significant AR maintain smaller LV volumes than younger patients and men, respectively, on serial evaluation. In addition, they have lower LV volume thresholds above which the rate of adverse events significantly increases. Our results suggest that the use of a singular LV threshold for intervention may lead to delayed referral and disproportionately worse outcomes in older patients and women. Hence, age-specific and sex-specific LV volume

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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