Original Investigation
Predictors of Progression in Patients With Stage B Aortic Regurgitation

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Abstract

Background

The natural history of stage B aortic regurgitation (AR) is unknown.

Objectives

This study sought to examine determinants, rate, and consequences of progression of AR.

Methods

Consecutive patients with ≤moderate chronic AR quantified by effective regurgitant orifice area (EROA) and regurgitant volume (RVol) from 2004 to 2017 who had ≥1 subsequent echocardiogram with quantitation were included.

Results

Of 1,077 patients (66 ± 15 years of age), baseline trivial/mild AR was noted in 196 (18%), mild-to-moderate AR in 465 (43%), and moderate AR in 416 (39%); 10-year incidence of progression to ≥moderate-severe AR (stage C/D; progressors) was 12%, 30%, and 53%, respectively. At 4.1-year follow-up (interquartile range: 2.1 to 7.2 years), there were 228 progressors (21%), whose annualized progression rates within 3 years before diagnosis of ≥moderate-severe AR were 4.2 mm2/year for EROA and 9.9 ml/year for RVol. Baseline AR severity and dimensions of sinotubular junction and annulus were associated with progression (all p ≤ 0.007); hypertension and systolic blood pressure were not. Progressors had faster chamber remodeling, functional class decline, and more aortic valve/aortic surgery. At medium-term follow-up, 242 patients (22%) died; poor survival was linked to age, comorbidities, functional class, resting heart rate, and left ventricular (LV) ejection fraction (p ≤ 0.003), not LV end-systolic dimension index. Survival after progression to stage C/D AR was associated with LV end-systolic dimension index (adjusted p = 0.02).

Conclusions

Progression from stage B to stage C/D AR was observed in 21% patients. Repeat echocardiography for trivial/mild, mild-to-moderate, and moderate AR at every 5, 3, and 1 years, respectively, was reasonable. EROA, RVol, annulus, and sinotubular junction should be routinely measured to estimate progression rates and identify patients at high risk of progression, which was associated with adverse consequences.

Key Words

aortic regurgitation
echocardiography
prognosis
progression

Abbreviations and Acronyms

AR
aortic regurgitation
AS
aortic stenosis
AV
aortic valve
AVR
aortic valve replacement
BAV
bicuspid aortic valve
CI
confidence interval
DBP
diastolic blood pressure
EROA
effective regurgitant orifice area
HR
hazard ratio
HTN
hypertension
IQR
interquartile range
LV
left ventricular
LVEDD
left ventricular end-diastolic dimension
LVEF
left ventricular ejection fraction
LVESD
left ventricular end-systolic dimension
LVESDi
left ventricular end-systolic dimension index
MR
mitral regurgitation
NYHA
New York Heart Association
PHT
pressure-half time
PISA
proximal isovelocity surface area
RHR
resting heart rate
RVol
regurgitant volume
SBP
systolic blood pressure
SoV
sinus of Valsalva
STJ
sinotubular junction
TTE
transthoracic echocardiogram
VCW
vena contracta width

Cited by (0)

This work was supported by internal funds from the Mayo Clinic Department of Cardiovascular Medicine. Dr. Pellikka is the Betty Knight Scripps Professor in Cardiovascular Diseases Clinical Research, the professorship supported this research. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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