Original Research
Do Guideline-Based Indications Result in an Outcome Penalty for Patients With Severe Aortic Regurgitation?

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Abstract

Objectives

The present study examines whether improvements have reduced the negative impact of guideline triggers on postoperative outcomes.

Background

European and American guidelines for the management of severe aortic regurgitation (AR) define the triggers for AR surgery. These triggers are based on the results of studies performed in the 1990s analyzing outcomes of patients who underwent AR surgery in the 1980s. Although these triggers are used to indicate surgery, they have all been associated with poorer postoperative outcomes. In the meantime, innovations in operative techniques, including aortic valve repair, have allowed reducing the risk of surgery.

Methods

A total of 356 consecutive patients undergoing surgical correction of severe AR were included in this study. Among them, 204 were operated on for a Class I, 17 for a Class IIa, 49 for a Class IIb, and 86 without any guideline triggers. Cox proportional hazards regression models and Kaplan-Meier survival curves were used to compare postoperative outcomes in the different groups. Inverse probability weighing was used to adjust for mismatched baseline characteristics.

Results

Adjusted 10-year survival was better among patients without operative triggers (89 ± 4%) or with Class II triggers (85 ± 6%) than in patients with Class I triggers (71 ± 4%, p = 0.010). Similar results were obtained for cardiovascular survival and hospitalizations for heart failure. Spline function analyses indicated that mortality started to increase for left ventricular (LV) ejection fraction <55% and LV end-systolic dimensions >20 to 22 mm/m2. LV end-diastolic dimensions did not influence outcomes.

Conclusions

Guideline-based Class I triggers for AR surgery carry major risks for long-term outcomes. This suggests that patients with severe AR should be operated on before the onset of these triggers; that is, at an asymptomatic stage, before LV ejection fraction falls below 55% or LV end-systolic dimensions exceeds 20 to 22 mm/m2.

Key Words

aortic regurgitation
aortic valve repair
early surgery
postoperative survival

Abbreviations and Acronyms

ACC
American College of Cardiology
AHA
American Heart Association
AR
aortic regurgitation
AV
aortic valve
BSA
body surface area
ESC
European Society of Cardiology
IPW
inverse probability weight
LVEDD
left ventricular end-diastolic dimensions
LVEF
left ventricular ejection fraction
LVESD
left ventricular end-systolic dimensions
NYHA
New York Heart Association

Cited by (0)

This work is supported by the Fonds National de la Recherche Scientifique (FNRS, Brussels, Belgium). The authors have reported that they have no relationships relevant to the contents of this paper to disclose.