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Background: There are no sex-specific guidelines for chronic aortic regurgitation (AR). This retrospective study examined sex-specific differences and propose treatment criteria from an Asian AR cohort., Methods and results: Consecutive 1,305 patients with moderate-severe AR or greater at 3 tertiary centers in Taiwan and Japan (2008-2022) were identified. Study endpoints were aortic valve surgery (AVS), all-cause death (ACD), and cardiovascular death (CVD). The median follow up was 3.9 years (interquartile range 1.3-7.1 years). Compared with men (n=968), women (n=337) were older, had more advanced symptoms, more comorbidities, larger indexed aorta size (iAorta max ) and indexed left ventricular (LV) end-systolic dimension (LVESDi; P<0.001 for all). Symptomatic status was poorly correlated with the degree of LV remodeling in women (P≥0.18). Women received fewer AVS (P≤0.001) and men had better overall 10-year survival (P<0.01). Ten-year post-AVS survival (P=0.9) and the progression of LV remodeling were similar between sexes (P≥0.16). Multivariable determinants of ACD and CVD were age, advanced symptoms, iAorta max , LV ejection fraction (LVEF), LVESDi, LV end-systolic volume index (LVESVi), and Taiwanese ethnicity (all P<0.05), but not female sex (P≥0.05). AVS was associated with better survival (P<0.01). Adjusted LVEF, LVESDi, LVESVi, and iAorta max cut-off values for ACD were 53%, 24.8 mm/m 2 , 44 mL/m 2 , and 25.5 mm/m 2 , respectively, in women and 52%, 23.4 mm/m 2 , 52 mL/m 2 , and 23.2 mm/m 2 , respectively, in men., Conclusions: Early detection and intervention using sex-specific cut-off values may improve survival in women with AR.

Importance: Chronic aortic regurgitation (AR) causes left ventricular (LV) volume overload, which results in progressive LV remodeling negatively affecting outcomes. Whether cardiac magnetic resonance (CMR) volumetric quantification can provide incremental risk stratification over standard clinical and echocardiographic evaluation in patients with chronic moderate or severe AR is unknown., Objective: To compare LV remodeling measurements by CMR and echocardiography between patients with and without heart failure symptoms and to verify the association of remodeling measurements of patients with chronic moderate or severe AR but no or minimal symptoms with clinical outcomes receiving medical management., Design, Setting, and Participants: This multicenter retrospective cohort study included consecutive patients with at least moderate chronic native AR evaluated by 2-dimensional transthoracic echocardiography and CMR examination within 90 days from each other between January 2012 and February 2020 at Allina Health System. Data were analyzed from June 2021 to January 2022., Exposures: Clinical evaluation and risk stratification by CMR., Main Outcomes and Measures: The end point was a composite of death, heart failure hospitalization, or progression of New York Heart Association functional class while receiving medical management, censoring patients at the time of aortic valve replacement (when performed) or at the end of follow-up., Results: Of the 178 included patients, 119 (66.9%) were male, 158 (88.8%) presented with no or minimal symptoms (New York Heart Association class I or II), and the median (IQR) age was 58 (44-69) years. Compared with patients with no or minimal symptoms, symptomatic patients had greater LV end-systolic volume index (LVESVi) by CMR (median [IQR], 66 [46-85] mL/m2 vs 42 [30-58] mL/m2; P < .001), while there were no significant differences by echocardiography (LVESVi: median [IQR], 38 [30-58] mL/m2 vs 27 [20-42] mL/m2; P = .07; LV end-systolic diameter index: median [IQR], 21 [17-25] mm/m2 vs 18 [15-22] mm/m2; P = .17). During the median (IQR) follow-up of 3.3 (1.6-5.8) years, 50 patients with no or minimal symptoms receiving medical management developed the composite end point, which, in multivariate analysis adjusted for age and EuroSCORE II, was independently associated with LVESVi of 45 mL/m2 or greater and aortic regurgitant fraction of 32% or greater, the latter adding incremental prognostic value to CMR volumetric assessment., Conclusions and Relevance: In patients with chronic moderate or severe AR, patients presenting with heart failure symptoms have greater LVESVi by CMR than those with no or minimal symptoms. In patients with no or minimal symptoms, CMR quantification of LVESVi and AR severity may identify those at risk of death or incident heart failure and therefore should be considered in the clinical evaluation and decision-making of these patients.

Background: Whether automated left ventricular global longitudinal strain (LVGLS) is associated with outcomes in patients with asymptomatic aortic regurgitation (AR) is unknown. The aim of this study was to explore the impact of automated LVGLS on survival and compare it with conventional left ventricular (LV) parameters in patients with chronic asymptomatic AR., Methods: LVGLS (presented as an absolute value) was measured using fully automated two-dimensional strain software in consecutive patients with isolated chronic moderate to severe or greater AR between 2004 and 2020; the incremental value of LVGLS was assessed. Limited correction of endocardial border tracking was performed if needed., Results: Of 550 asymptomatic patients (mean age, 60 ± 17 years; 86% men), average LVGLS was 17 ± 3% (first and second tertiles, 15.8% and 18.5%). In 16% of cases, tracking border was partially corrected; average time for analysis was 25 ± 5 sec. At a median of 4.8 years (interquartile range, 1.5-9.9 years), 87 patients had died (19 died after aortic valve surgery). Separate multivariable models adjusted for age, sex, Charlson index, AR severity, and time-dependent aortic valve surgery demonstrated that LV ejection fraction (hazard ratio [HR] per 10%, 0.9), LV end-systolic volume index (LVESVi; HR per 5 mL/m 2 , 1.08) and LVGLS (HR per unit, 0.87) were independently associated with death (P ≤ .018 for all); however, LVGLS remained statistically significant (HR: 0.86-0.9; P ≤ .007) when compared head-to-head with LV ejection fraction, LVESVi, and LV end-systolic dimension index. The association of LVGLS and mortality was consistent across all subgroups (P for interaction ≥ .08 for all). Spline curves showed that continuous risk for death rose at LVGLS < 15%. Those with LVGLS < 15% had a 2.6-fold risk for death (95% CI, 1.54-4.23) while those with LVGLS < 15% plus LVESVi ≥ 45 mL/m 2 had 3.96-fold risk (95% CI, 1.94-8.03)., Conclusions: In this large cohort of asymptomatic patients with moderate to severe or greater AR, automated LVGLS was feasible, efficient, and independently associated with death in head-to-head comparisons with conventional LV ejection fraction, LV end-systolic dimension index, and LVESVi. An automated LVGLS threshold of <15% alone or combined with LVESVi ≥ 45 mL/m 2 was significantly associated with increased mortality risk and may be considered in early surgery decision-making., (Copyright © 2022 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Objective: To examine contemporary clinical differences between men and women with hemodynamically significant chronic aortic regurgitation (AR)., Patients and Methods: We retrospectively identified 1072 consecutive patients with moderate to severe or severe AR diagnosed between February 21, 2004, and April 29, 2019. Echocardiographic data, aortic valve surgical intervention (AVS), and all-cause death were analyzed., Results: At baseline, the 189 women in the study group were older than the 883 men (mean ± SD age, 64±18 years vs 58±17 years), had more advanced symptoms, and had larger left ventricular end-systolic dimension index (LVESDi) (all P<.001) despite similar AR severity. An LVESDi of greater than 20 mm/m 2 was noted in 60 of 92 asymptomatic women (65%) vs 225 of 559 asymptomatic men (40%) (P<.001). Median follow-up was 5.6 years (interquartile range, 2.5 to 10.0 years). Female sex was associated with less AVS (P=.009), and overall 10-year survival was better in men (76%±2%) than in women (64%±5%) (P=.004). However, 10-year post-AVS survival was similar between the sexes (P=.86), and women had better left ventricular reverse remodeling than men regarding end-diastolic dimension (P=.02). Multivariable independent predictors of death were age, advanced symptoms, LVESDi, ejection fraction, and AVS (all P≤.03) but not female sex. When compared with the age-matched US population, women exhibited a 1.3-fold increased relative risk of death (P=.0383) while men had similar survival (P=.11)., Conclusion: In contemporary practice, women with AR continue to exhibit an overall survival penalty not related to female sex but to late referral markers, including more advanced symptoms, larger LVESDi, and less AVS. Nonetheless, women in our study exhibited outstanding post-AVS left ventricular remodeling and had good post-AVS survival, a step forward toward closing the sex-related mortality gap. The high percentage of LVESDi of 20 mm/m 2 or greater in asymptomatic women represents a window of opportunity for advanced-symptom prevention and timely AR surgical correction that may close the mortality gap., (Copyright © 2021 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To comprehensively explore contemporary differences between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with chronic haemodynamically significant aortic regurgitation (AR)., Methods: Consecutive patients with chronic ≥moderate-severe AR from a tertiary referral centre (2006-2017) were included. All-cause mortality, surgical indications and aortic valve surgery (AVS) were analysed., Results: Of 798 patients (296 BAV-AR, age 46±14 years; 502 TAV-AR, age 67±14 years, p<0.0001) followed for 5.5 (IQR: 2.9-9.2) years, 403 underwent AVS (repair in 96) and 154 died during follow-up. The 8-year AVS incidence was 60%±3% versus 53%±3% for BAV-AR and TAV-AR, respectively (p=0.014). The unadjusted (real-life) 8-year total survival was 93%±7% versus 71%±2% for BAV-AR and TAV-AR, respectively (p<0.0001), and became statistically insignificant after sole adjustment for age (p=0.14). The within-group relative risk of death in BAV-AR patients demonstrated a large age-dependent increase (two fold at 50-55 years, up to 10-fold at 70 years). The presence of baseline symptoms was significantly associated with death for both BAV-AR (p=0.039) and TAV-AR (p<0.0001), but the strength of the association decreased with age adjustment for BAV-AR (age-adjusted HR 2.43 (0.92-6.39), p=0.07) and not for TAV-AR (age-adjusted HR, 2.3 (1.6-3.3), p<0.0001). As compared with general population, TAV-AR exhibited baseline excess risk which further increased at left ventricular ejection fraction (LVEF) <60% and left ventricular end-systolic dimension index (LVESDi) >20 mm/m 2 ; similar thresholds were observed for BAV-AR patients., Conclusion: BAV-AR patients were two decades younger than TAV-AR and underwent AVS more frequently, resulting in a considerable real-life survival advantage for BAV-AR that was determined primarily by age and not valve anatomy. Pragmatically, regardless of valve anatomy, patients with haemodynamically significant AR and age >50-55 years require a low-threshold for surgical referral to prevent symptom development where LVEF <60% and LVESDi >20 mm/m 2 seem appropriate referral thresholds., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Volumetric measurements by transthoracic echocardiogram may better reflect left ventricular (LV) remodeling than conventional linear LV dimensions. However, the association of LV volumes with mortality in patients with chronic hemodynamically significant aortic regurgitation (AR) is unknown., Objective: To assess whether LV volumes and volume-derived LV ejection fraction (Vol-LVEF) are determinants of mortality in AR., Design, Setting, and Participants: This cohort study included consecutive asymptomatic patients with chronic moderately severe to severe AR from a tertiary referral center (January 2004 through April 2019)., Exposures: Clinical and echocardiographic data were analyzed retrospectively. Aortic regurgitation severity was graded by comprehensive integrated approach. De novo disk-summation method was used to derive LV volumes and Vol-LVEF., Main Outcome and Measures: Associations between all-cause mortality under medical surveillance and the following LV indexes: linear LV end-systolic dimension index (LVESDi), linear LVEF, LV end-systolic volume index (LVESVi), and Vol-LVEF., Results: Of 492 asymptomatic patients (mean [SD] age, 60 [17] years; 425 men [86%]), ischemic heart disease prevalence was low (41 [9%]), and 453 (92.1%) had preserved linear LVEF (≥50%) with mean (SD) LVESVi of 41 (15) mL/m2. At a median (interquartile range) of 5.4 (2.5-10.1) years, 66 patients (13.4%) died under medical surveillance; overall survival was not different than the age- and sex-matched general population (P = .55). Separate multivariate models, adjusted for age, sex, Charlson Comorbidity Index, and AR severity, demonstrated that in addition to linear LVEF and LVESDi, LVESVi and Vol-LVEF were independently associated with mortality under surveillance (all P < .046) with similar C statistics (range, 0.83-0.84). Spline curves showed that continuous risks of death started to rise for both linear LVEF and Vol-LVEF less than 60%, LVESVi more than 40 to 45 mL/m2, and LVESDi above 21 to 22 mm/m2. As dichotomized variables, patients with LVESVi more than 45 mL/m2 exhibited increased relative death risk (hazard ratio, 1.93; 95% CI, 1.10-3.38; P = .02) while LVESDi more than 20 mm/m2 did not (P = .32). LVESVi more than 45 mL/m2 showed a decreased survival trend compared with expected population survival., Conclusions and Relevance: In this large asymptomatic cohort of patients with hemodynamically significant AR, LVESVi and Vol-LVEF worked equally as well as LVESDi and linear LVEF in risk discriminating patients with excess mortality. A LVESVi threshold of 45 mL/m2 or greater was significantly associated with an increased mortality risk.

Background: Etiology, mechanisms, and survival of mitral regurgitation (MR) plus hemodynamically-significant chronic aortic regurgitation (AR) are mostly unknown., Objectives: The purpose of this study was to investigate the prevalence, mechanisms, etiologies, and survival impact of coexistent ≥ moderate MR in AR patients., Methods: Consecutive patients with ≥ moderate-severe AR were retrospectively identified between 2004 and 2019., Results: Of 1,239 eligible patients (61 ± 18 years, 80% men), 1,072 (86%) had pure AR, and 167 (14%) had AR + MR (9% functional mitral regurgitation [FMR] [84% nonischemic] and 5% organic mitral regurgitation [OMR] [62% degenerative]). At baseline transthoracic echocardiogram, pure AR versus AR + OMR versus AR + FMR exhibited differences in age (59 ± 18, 62 ± 16, and 73 ± 14 years, respectively), female sex (18%, 27%, and 39%, respectively), symptoms (36%, 41%, and 64%, respectively), atrial fibrillation (5%, 17%, and 36%, respectively), left ventricular (LV) ejection fraction (59%, 58%, and 46%, respectively), LV end-systolic dimension and volume index, ≥ moderate tricuspid regurgitation (TR) (7%, 35%, and 53%, respectively), and right ventricular systolic pressure (32 ± 11, 45 ± 15, and 50 ± 14 mm Hg, respectively), all p < 0.0001. After a median follow-up of 5.2 years (interquartile range: 2.2 to 10.0 years) and adjusting for demographics, New York Heart Association functional class, aortic valve surgery, LV ejection fraction, LV end-systolic dimension and volume index, presence of FMR was independently associated with all-cause mortality (p ≤ 0.004). Compared with pure AR, AR + MR + TR exhibited the highest adjusted risk of death (2.4-fold; p < 0.0001). When compared with expected population survival, excess mortality risks of pure AR, AR + OMR, and AR + FMR were 1.25-fold, 1.76-fold, and 2.34-fold, respectively (all p ≤ 0.02)., Conclusions: In hemodynamically significant AR, coexistent MR is not uncommon (approximately 14%) and mostly comprises FMR and less commonly OMR. As compared with pure AR, AR + MR + TR exhibit the largest mortality risk. Both AR + OMR and AR + FMR carry a survival penalty compared with the general population, but AR + FMR is associated with the largest excess mortality and represents an advanced stage within the AR clinical spectrum., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The prognostic significance of diastolic blood pressure (DBP) and resting heart rate (RHR) in patients with hemodynamically significant aortic regurgitation (AR) is unknown., Objectives: This study sought to investigate the association of DBP and RHR with all-cause mortality in patients with AR., Methods: Consecutive patients with ≥ moderate to severe AR were retrospectively identified from 2006 to 2017. The association between all-cause mortality and routinely measured DBP and RHR was examined., Results: Of 820 patients (age 59 ± 17 years; 82% men) followed for 5.5 ± 3.5 years, 104 died under medical management, and 400 underwent aortic valve surgery (AVS). Age, symptoms, left ventricular ejection fraction (LVEF), LV end-systolic diameter-index (LVESDi), DBP, and RHR were univariable predictors of all-cause mortality (all p ≤ 0.002). When adjusted for demographics, comorbidities, and surgical triggers (symptoms, LVEF, and LVESDi), baseline DBP (adjusted-hazard ratio [HR]: 0.79 [95% confidence interval: 0.66 to 0.94] per 10 mm Hg increase, p = 0.009) and baseline RHR (adjusted HR: 1.23 [95% confidence interval: 1.03 to 1.45] per 10 beat per min [bpm] increase, p = 0.01) were independently associated with all-cause mortality. These associations persisted after adjustment for presence of hypertension, medications, time-dependent AVS, and using average DBP and RHR (all p ≤ 0.02). Compared with the general population, patients with AR exhibited excess mortality (relative risk of death >1), which rose steeply in inverse proportion (p nonlinearity = 0.002) to DBP starting at 70 mm Hg and peaking at 55 mm Hg and in direct proportion to RHR starting at 60 bpm., Conclusions: In patients with chronic hemodynamically significant AR, routinely measured DBP and RHR demonstrate a robust association with all-cause death, independent of demographics, comorbidities, guideline-based surgical triggers, presence of hypertension, and use of medications. Therefore, DBP and RHR should be integrated into comprehensive clinical decision-making for these patients., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

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 mm 2 /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., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Bicuspid aortic valve (BAV) and mitral valve prolapse (MVP) are common but the prevalence and significance of coexistent conditions are unknown. This study investigated the prevalence, phenotypic expression, and clinical significance of coexistent MVP-BAV., Methods and Results: Retrospective comparison of MVP-BAV and MVP-tricuspid aortic valve (TAV) prevalence including de novo echocardiographic analysis of all MVP-BAV patients between 2005 and 2015 was performed. The community prevalence of MVP-BAV was 2.7% vs. 3.4% for MVP-TAV (P = 0.45). Posterior mitral leaflet (PML)-MVP was the most common phenotype in both BAV and TAV (P = 0.38), but anterior mitral leaflet (AML)-MVP was twice more prevalent in BAV (31% vs. 15%, P < 0.0001). Among 130 subjects with coexistent MVP-BAV (81% men, 51 ± 16 years old), 31 (24%) exhibited AML:PML length ratio ≥3:1, termed large-AML prolapse (LAP-BAV), who had predominant BAV regurgitation when compared with those with non-LAP-BAV (P ≤ 0.001). An extreme phenotype of LAP-BAV with giant-AML prolapse and diminutive PML (GAP-BAV) was identified in 18/130 (14%) subjects. Compared with posterior-MVP-BAV, GAP-BAV patients were younger (42 ± 15 vs. 64 ± 12 years, P < 0.0001), had larger aortic annulus (28 ± 3 vs. 26 ± 2 mm, P = 0.01), and 61% had ≥ moderate BAV regurgitation (vs. 16%, P = 0.0007). Mitral repair occurred in 37/130 (28%) subjects. After median follow-up 5.5 months (4-83), 4/5 (80%) GAP-BAV patients required redo surgery for recurrent mitral regurgitation vs. 2/31 (6%) for non-LAP-BAV (P = 0.001)., Conclusion: The community prevalence of coexistent MVP-BAV is comparable to MVP-TAV and their most common phenotype is posterior-MVP. However, anterior-MVP is twice as prevalent in MVP-BAV. A large-AML phenotype (LAP-BAV) with predominant BAV regurgitation affects 24% of MVP-BAV patients. An extreme phenotype of anterior-MVP (GAP-BAV) affects 14% of BAV patients; characterized by exceptionally large AML, diminutive PML, high mitral and aortic regurgitation prevalence, and high mitral repair failure rate., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.)

Objectives: Current national registries are lacking detailed pathology-driven analysis and long-term patients outcomes. The Heart Valve Society (HVS) aortic valve (AV) repair research network started the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) to evaluate long-term patient outcomes of AV repair and replacement. The purpose of the current report is to describe the AVIATOR initiative and report in a descriptive manner the patients included., Methods: The AV repair research network includes surgeons, cardiologists, and scientists and established an online database compliant with the guidelines for reporting valve-related events. Prospective inclusion started from January 2013. Adult patients (18 years or older) who were operated on between 1995 and 2017 with complete procedural specification of the type of repair/replacement were selected for descriptive analysis., Results: Currently 58 centers from 17 countries include 4896 patients with 89% AV repair (n = 4379) versus 11% AV replacement (n = 517). AV repair was either isolated (28%), or associated with tubular/partial root replacement (22%) or valve-sparing root replacement (49%) with an in-hospital mortality of 0.5%, 1.7%, and 1.2%, respectively. AV replacement was either isolated (24%), associated with tubular/partial root replacement (17%) or root replacement (59%) with an in-hospital mortality of 1%, 2.6%, and 2.0%, respectively., Conclusions: The multicenter surgical AVIATOR registry, by applying uniform definitions, should provide a solid evidence base to evaluate the place of repair versus replacement on the basis of long-term patient outcomes. Obtaining data completeness and adequate representation of all surgery types remain challenging. Toward the near future AVIATOR-medical will start to study natural history, as will AVIATOR-kids, with a focus on pediatric disease., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Few data exist on the contemporary profiles and outcomes of patients with significant aortic regurgitation (AR)., Objectives: This study sought to assess the benefits of aortic valve repair or replacement (AVR) and the prognostic value of left ventricular (LV) dimensions in significant AR., Methods: From 2006 to 2017, consecutive patients with ≥moderate-severe chronic AR without prior heart surgery, myocardial infarction, or overt coronary artery disease were included., Results: Of 748 participants (58 ± 17 years of age; 82% men), 387 (52%) were medically treated, and 361 (48%) had AVR. Of 361 patients having AVR, 334 (93%) met guideline criteria: Class I indications in 284 (79%) patients, which included symptoms in 236, and Class II indications in 50 (14%). The remaining 27 (7%) opted for surgery without Class I or II indications. At a median follow-up of 4.9 years (interquartile range: 2.3 to 8.3 years), 125 (17%) patients had died. Age, comorbidities, baseline symptoms, and higher LV end-systolic dimension index (LVESDi) were associated with all-cause mortality (all p ≤ 0.01). Compared with patients having LVESDi <20 mm/m 2 , those with LVESDi 20 to 25 mm/m 2 (hazard ratio: 1.53; 95% confidence interval: 1.01 to 2.31) and ≥25 mm/m 2 (HR: 2.23; 95% confidence interval: 1.32 to 3.77) had increased risks of death. AVR was associated with better survival (p < 0.0001). Patients with Class I indications for surgery had inferior post-operative survival (p < 0.003)., Conclusions: Class I indications for surgery, mainly symptoms, are the most common triggers for AVR. Class II indications were associated with better post-operative outcome and thus merit more attention. LVESDi was the only LV parameter independently associated with all-cause mortality and the ideal cutoff seems to be lower than previously recommended., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Sex-related differences in morbidity and survival in bicuspid aortic valve (BAV) adults are fundamentally unknown. Contemporary studies portend excellent survival for BAV patients identified at early echocardiographic-clinical stages. Whether BAV adults incur a survival disadvantage throughout subsequent echocardiographic-clinical stages remains undetermined., Methods and Results: Analysis was done of 3 different cohorts of consecutive patients with echocardiographic diagnosis of BAV identified retrospectively: (1) a community cohort of 416 patients with first BAV diagnosis (age 35±21 years, follow-up 16±7 years), (2) a tertiary clinical referral cohort of 2824 BAV adults (age 51±16 years, follow-up 9±6 years), and (3) a surgical referral cohort of 2242 BAV adults referred for aortic valve replacement (AVR) (age 62±14 years, follow-up 6±5 years). For the community cohort, 20-year risks of aortic regurgitation (AR), AVR, and infective endocarditis were higher in men (all P≤0.04); for a total BAV-related morbidity risk of 52±4% vs 35±6% in women (P=0.01). The cohort's 25-year survival was identical to that in the general population (P=0.98). AR independently predicted mortality in women (P=0.001). Baseline AR was more common in men (P≤0.02) in the tertiary cohort, with 20-year survival lower than that in the general population (P<0.0001); age-adjusted relative death risk was 1.16 (95% confidence interval [CI] 1.05-1.29) for men versus 1.67 (95% CI 1.38-2.03) for women (P=0.001). AR independently predicted mortality in women (P=0.01). Baseline AR and infective endocarditis were higher in men (both ≤0.001) for the surgical referral cohort, with 15-year survival lower than that in the general population (P<0.0001); age-adjusted relative death risk was 1.34 (95% CI 1.22-1.47) for men versus 1.63 (95% CI 1.40-1.89) for women (P=0.026). AR and NYHA class independently predicted mortality in women (both P≤0.04)., Conclusions: Within evolving echocardiographic-clinical stages, the long-term survival of adults with BAV is not benign, as both men and women incur excess mortality. Although BAV-related morbidity is higher in men in the community, and AR and infective endocarditis are more prevalent in men, women exhibit a significantly higher relative risk of death in tertiary and surgical referral cohorts, which is independently associated with AR., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: The aim of this study was to assess contractile reserve (CR) in patients with severe aortic regurgitation (AR), and potential clinical applications of CR in minimally symptomatic patients., Methods and Results: Symptom-limited treadmill exercise echocardiography was performed in 58 asymptomatic or mildly symptomatic patients with chronic severe AR (male 69%, 50±14 years). Patients with increased ejection fraction (EF) after exercise were denoted as having CR (+) and those without increased EF were categorized as CR (-). CR (+) was found in 31 and CR (-) in 27 patients. Compared with CR (+), the CR (-) group had lower EF, larger effective regurgitant orifice, regurgitant volume, left ventricular (LV) end-diastolic dimension, LV end-systolic dimension (LVESD), and LV mass index. On multiple logistic regression analysis LVESD index (LVESDI; odds ratio -0.354, P<0.0001) was an independent predictor of CR. One-third of patients with LVESD >50mm, however, were found to be CR (+), while one-third of patients with smaller LVESD were CR (-)., Conclusions: Although CR is best related to baseline resting LVESDI, one-third of patients were found to have discordance between the presence of CR and the LV dimension recommended for aortic valve replacement (AVR) in minimally symptomatic patients with severe AR, suggesting that exercise test may be able to further stratify the current guideline for AVR.

Background: Recent studies have emphasized the importance of quantitative assessment of the degree of aortic regurgitation (AR). However, semiquantitative methods have remained mainly used despite their unclear diagnostic value. The aim of this study was to define the sensitivity and specificity of semiquantitative methods compared with the proximal isovelocity surface area method as a reference for the diagnostic of severe AR., Methods: The degree of AR was evaluated using the proximal isovelocity surface area method and four semiquantitative measurements (left ventricular cardiac output, pressure half-time, diastolic flow reversal, and vena contracta) in 224 patients with a wide range of AR severity., Results: The mean effective regurgitant orifice area was 25 ± 14 mm(2) (range, 3-69 mm(2)), the mean regurgitant volume was 57 ± 31 mL (range, 9-183 mL), and 100 patients (44%) had severe AR (effective regurgitant orifice area ≥ 30 mm(2) or regurgitant volume ≥ 60 mL). Overall, semiquantitative methods had good specificity but poor sensitivity, except the vena contracta, which had good sensitivity and specificity. Sensitivity, specificity, and positive and negative predictive values of the recommended thresholds for severe AR of the four semiquantitative methods were 53%, 89%, 77%, and 73% for left ventricular cardiac output ≥ 10 L/min; 12%, 100%, 100%, and 52% for pressure half-time < 200 msec; 45%, 87%, 79%, and 60% for diastolic flow reversal ≥ 18 cm/sec; and 81%, 83%, 78%, and 85% for vena contracta ≥ 6 mm, respectively., Conclusions: For the assessment of AR severity, current thresholds appear specific but poorly sensitive, except for vena contracta, which provides good discriminative value. Semiquantitative methods should be integrated into the comprehensive evaluation of AR severity, but severe AR should not be excluded only on the basis of semiquantitative criteria. These results emphasize the need for the quantitative assessment of AR severity., (Copyright © 2011 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Objectives: We examined the role of prosthesis-patient mismatch on left ventricular mass regression after aortic valve replacement for chronic aortic valve regurgitation., Methods: We selected patients who had complete preoperative and follow-up echocardiograms with measurement of left ventricular mass. Patients were excluded who had moderate or greater aortic valve stenosis, concomitant coronary artery bypass grafting, or mitral valve procedures., Results: Patients' mean age was 55 ± 17 years; 21% were female. The mean preoperative indexed left ventricular mass was 150 ± 45 g/m(2). Patients with mildly (n = 44; mean indexed mass, 126 ± 15 g/m(2)), moderately (n = 31; mean indexed mass, 168 ± 11 g/m(2)), or severely (n = 15; mean indexed mass, 241 ± 34 g/m(2)) increased preoperative indexed left ventricular mass, were similar, except for lower ejection fractions, larger end-diastolic dimensions, and larger ventricular wall thicknesses in the severely enlarged group (P < .001). Thirteen patients had prosthesis-patient mismatch and were similar to patients without prosthesis-patient mismatch, except for a greater body surface area, fewer mechanical valves, and smaller valve sizes in those with prosthesis-patient mismatch (P < .05). At a mean follow-up of 3.2 ± 2.4 years, the average reduction in indexed left ventricular mass was 50 ± 38 g/m(2); late mass regression was unrelated to labeled valve size, prosthesis-patient mismatch, or measured indexed effective aortic valve area. A greater preoperative indexed left ventricular mass (P < .001) was an independent predictor of greater left ventricular mass regression. Despite having greater left ventricular mass regression, patients with severe preoperative indexed left ventricular mass did not return to normal values (mean, 142 ± 25 g/m(2))., Conclusions: Left ventricular mass regression after aortic valve replacement for chronic aortic regurgitation is unrelated to indexed prosthetic valve area. Although incomplete, regression is greatest in patients with the largest preoperative indexed left ventricular mass., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

A 67-year-old male who had received an aortic porcine bioprosthesis 15 years previously, presented with unstable angina. The patient underwent percutaneous coronary intervention with the resolution of chest pain. A limited predischarge echocardiogram showed evidence of a newly severely elevated left ventricular filling pressure and new eccentric aortic regurgitation. Six days later, the patient reported symptoms of heart failure. Transesophageal echocardiography (TEE) revealed severe aortic regurgitation due to a torn/flail left coronary cusp; this was confirmed surgically and pathologically, and required aortic valve re-replacement. The present case highlights the value of indirect echocardiographic signs of aortic regurgitation and the value of TEE in the accurate identification of the mechanism of complex prosthetic valvular heart disease, with excellent pathological correlation. The temporal relationship between the valve tear and coronary intervention raises a point of caution and an awareness in the practice of catheter-based percutaneous procedures in patients with 'old' bioprosthetic aortic valves that are likely more prone to anatomic disruption.

Objective: Congestive heart failure complicating aortic regurgitation is poorly described, and predictive roles of quantitative versus traditional (symptoms or low ejection fraction) surgical markers are unclear., Methods: We prospectively enrolled 287 patients with aortic regurgitation (age, 61 +/- 17 years; 68% male) in whom we performed quantitative Doppler echocardiographic analysis and personal physicians conducted management., Results: After diagnosis, 40 congestive heart failure episodes occurred under medical management (10-year, 23% +/- 4%) causing high subsequent mortality (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.2-6.8; P = .02). Patients with traditional surgical markers (symptoms or ejection fraction <50%) were surprisingly followed 1.4 +/- 3.3 years under medical management with frequent congestive heart failure (adjusted risk, 4.9; 95% CI, 2.1-11.0; P < .001) and excess postoperative mortality (HR, 3.0; 95% CI, 1.3-7.1; P = .01). Quantitative American Society of Echocardiography aortic regurgitation grading and left ventricular end-systolic volume index independently predicted congestive heart failure (quantitative American Society of Echocardiography severe aortic regurgitation: HR, 3.6; 95% CI, 1.3-13.0; P = .015; end-systolic volume index >or=45 mL/m(2): HR, 2.1; 95% CI, 1.03-4.4; P = .04) or death-congestive heart failure with incremental predictive value (P < .001). Higher congestive heart failure rates occurred with quantitative American Society of Echocardiography severe aortic regurgitation (regurgitant volume of >or=60 mL/beat or orifice of >or=30 mm(2)) versus quantitative American Society of Echocardiography mild aortic regurgitation (10-year: 44% +/- 10% vs 15% +/- 7%, P < .001) and end-systolic volume index of 45 mL/m(2) or greater versus less than 45 mL/m(2) (33% +/- 7% vs 9% +/- 2%, P < .001). Traditional markers (symptoms and ejection fraction <50%) had lower sensitivity for congestive heart failure than quantitative echocardiography (all P < .001). Cardiac surgery for aortic regurgitation markedly reduced congestive heart failure in quantitative American Society of Echocardiography severe aortic regurgitation (HR, 0.23; 95% CI, 0.08-0.68; P = .008) without excess mortality (P = .10)., Conclusion: This prospective study of aortic regurgitation shows frequent congestive heart failure under conservative management. Traditional surgical markers (symptoms and ejection fraction <50%) predict subsequent congestive heart failure but are insensitive, and rescue operations are often delayed and associated with excess mortality. Quantitative echocardiography provides congestive heart failure predictors that are independent, incremental, and more sensitive than traditional markers. Cardiac surgery for aortic regurgitation markedly reduces congestive heart failure rates in high-risk patients with aortic regurgitation.

Background: Bicuspid aortic valve is frequent and is reported to cause numerous complications, but the clinical outcome of patients diagnosed with normal or mildly dysfunctional valve is undefined., Methods and Results: In 212 asymptomatic community residents from Olmsted County, Minn (age, 32+/-20 years; 65% male), bicuspid aortic valve was diagnosed between 1980 and 1999 with ejection fraction > or =50% and aortic regurgitation or stenosis, absent or mild. Aortic valve degeneration at diagnosis was scored echocardiographically for calcification, thickening, and mobility reduction (0 to 3 each), with scores ranging from 0 to 9. At diagnosis, ejection fraction was 63+/-5% and left ventricular diameter was 48+/-9 mm. Survival 20 years after diagnosis was 90+/-3%, identical to the general population (P=0.72). Twenty years after diagnosis, heart failure, new cardiac symptoms, and cardiovascular medical events occurred in 7+/-2%, 26+/-4%, and 33+/-5%, respectively. Twenty years after diagnosis, aortic valve surgery, ascending aortic surgery, or any cardiovascular surgery was required in 24+/-4%, 5+/-2%, and 27+/-4% at a younger age than the general population (P<0.0001). No aortic dissection occurred. Thus, cardiovascular medical or surgical events occurred in 42+/-5% 20 years after diagnosis. Independent predictors of cardiovascular events were age > or =50 years (risk ratio, 3.0; 95% confidence interval, 1.5 to 5.7; P<0.01) and valve degeneration at diagnosis (risk ratio, 2.4; 95% confidence interval, 1.2 to 4.5; P=0.016; >70% events at 20 years). Baseline ascending aorta > or =40 mm independently predicted surgery for aorta dilatation (risk ratio, 10.8; 95% confidence interval, 1.8 to 77.3; P<0.01)., Conclusions: In the community, asymptomatic patients with bicuspid aortic valve and no or minimal hemodynamic abnormality enjoy excellent long-term survival but incur frequent cardiovascular events, particularly with progressive valve dysfunction. Echocardiographic valve degeneration at diagnosis separates higher-risk patients who require regular assessment from lower-risk patients who require only episodic follow-up.

Objectives: The purpose of this study was to define the link between aortic regurgitation (AR) quantitation and clinical outcome in asymptomatic patients with AR., Background: Quantitative American Society of Echocardiography (QASE) thresholds are recommended for AR assessment, but impact on clinical outcome is unknown., Methods: We prospectively enrolled (1991 to 2003) 251 asymptomatic patients (age 60 +/- 17 years) with isolated AR and ejection fraction > or =50% with quantified AR and left ventricular (LV) volumes using Doppler-echocardiography., Results: Survival under medical management was independently determined by baseline regurgitant volume (RVol) (adjusted hazard ratio [HR] 1.22 [95% confidence interval (CI) 1.08 to 1.35] per 10 ml/beat, p = 0.002) and effective regurgitant orifice (ERO) (adjusted HR 1.52 [95% CI 1.19 to 1.91] per 10 mm(2), p = 0.002), which superseded traditional AR grading. Patients with QASE-severe AR (RVol > or =60 ml/beat or ERO > or =30 mm(2)) versus QASE-mild AR (RVol <30 ml and ERO <10 mm(2)) had lower survival (10 years: 69 +/- 9% vs. 92 +/- 4%, p = 0.05) independently of all clinical characteristics (adjusted HR 4.1 [95% CI 1.4 to 14.1], p = 0.01) and lower survival free of surgery for AR (10 years: 20 +/- 5% vs. 92 +/- 4%, p < 0.001, adjusted HR 12.9 [95% CI 5.4 to 38.5]). Cardiac events were considerably more frequent with QASE-severe versus -moderate or -mild AR (10 years: 63 +/- 8% vs. 34 +/- 6% and 21 +/- 8%, p < 0.0001). Independent determinants of cardiac events were quantitative AR grading (QASE-severe adjusted HR 5.2 [95% CI 2.2 to 14.8], p < 0.001; QASE-moderate adjusted HR 2.4 [95% CI 1.06 to 6.6], p = 0.035), which superseded traditional AR assessment (p < 0.001) and LV end-systolic volume index (ESVI) (adjusted HR 1.09 [95% CI 1.03 to 1.14 per 10 ml/m(2)], p = 0.002), which superseded LV M-mode diameters. In QASE-severe AR, patients with ESVI > or =45 versus <45 ml/m(2) had higher cardiac event rates (10 years: 87 +/- 8% vs. 40 +/- 10%, p < 0.001). Cardiac surgery for AR reduced cardiac events in patients with QASE-severe AR (adjusted HR 0.23 [95% CI 0.09 to 0.57], p = 0.002)., Conclusions: Echocardiographic quantitation of AR severity and ESVI provides independent and superior predictors of clinical outcome in asymptomatic patients with AR and ejection fraction > or =50% and should be widely clinically applied. Patients with QASE-severe AR and ESVI > or =45 ml/m(2) should be carefully considered for cardiac surgery, which reduces cardiac events risk.

Aortic regurgitation (AR) is a valve disease that causes severe complications and reduces life expectancy. Surgical correction is required in the late stages of the disease. In less advanced forms, treatment with vasodilators is a consideration. The available evidence suggests that this type of treatment has a favorable effect on the consequences of AR, particularly left ventricular remodeling. However, the impact of vasodilators on clinical endpoints complicating the course of AR remains in doubt. The limited evidence supporting or opposing the utilization of vasodilators in AR hinders drawing firm conclusions and emphasizes the process of individualized interpretation of the clinical presentation of patients with the disease.

Echocardiography is the key examination in the assessment of mitral and aortic regurgitation, as it is able to describe the etiology and mechanism of the disease and assess its severity and its repercussions on cardiac cavities and pulmonary pressures. Surgery now tends to be indicated at earlier stages, largely based on criteria drawn from echocardiography. In severe mitral regurgitation, surgery is not disputed in presence of left ventricular ejection fraction < 60% and/or end-systolic diameter > 45 mm. In a selected group of patients aged < 75 years, with a very high likelihood of successful repair and a low operative risk, surgery should be considered earlier (if ejection fraction is > 60% and end-systolic diameter < 45 mm) in degenerative regurgitation such as flail leaflets. In aortic regurgitation, surgery should be considered in presence of an acceptable operative risk as soon as end-systolic diameter exceeds 25 mm/m2 (and/or end-diastolic diameter > 70 mm) or resting ejection fraction < 55%. Surgery should be performed rapidly in dystrophic aortic regurgitation, independent of its severity, if the diameter of the ascending aorta exceeds 50 or 55 mm, or if it increases rapidly during follow-up. Echocardiography is therefore at the center of the strategic discussion concerning the indication for and timing of surgery.

In the presence of symptomatic aortic insufficiency, the indication for surgery is accepted. On the other hand, when the patient is asymptomatic, there is hesitation between intervening too early because of the operative risk and complications of valvular prostheses, and operating too late because of the progressive spontaneous risk of aortic parietal complications, sudden death or irreversible left ventricular dysfunction. Before any discussion, it is logical to verify the asymptomatic character of the patient with a stress test. On knowing the severity of the aortic insufficiency, which is usually confirmed by Doppler echocardiography, the decision is based partly on the left ventricular effects and the ascending aortic diameters, and partly on the operative risk modified by age and associated pathologies. In this article, drawing on the data in the literature we set out to discuss the operative indications in asymptomatic chronic aortic insufficiency.

Background: Left ventricular dysfunction is an indication for aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR). However, the postoperative outcome of patients with severe AR and a markedly low ejection fraction (EF) is not known., Methods and Results: The study group consisted of a total of 450 patients who had AVR for isolated AR between 1980 and 1995. Patients with markedly reduced left ventricular function (EF <35%, LoEF, n=43) were compared with those with moderate reduction in left ventricular function (EF 35% to 50%, MedEF, n=134) and those with normal left ventricular function (EF > or =50%, Nl EF, n=273). The operative mortality rate was higher with LoEF (14%) than with MedEF and Nl EF (6.7% and 3.7%, respectively, P=0.02). At 10 years, 41%+/-9% of LoEF patients had survived compared with 56%+/-5% and 70%+/-3% of MedEF and Nl EF patients, respectively (P<0.0001). Congestive heart failure occurred at 10 years in 25%+/-9% with LoEF compared with 17%+/-4% and 9%+/-2% with MedEF and NL EF, respectively (P<0.003). Postoperative EF improved by 4.9%+/-13.8% in the LoEF group and by 4%+/-11.9% in the MedEF group compared with -2.3%+/-10.9% in the Nl EF group (P<0.002 and P<0.0001, respectively)., Conclusions: Patients with severe AR and markedly low EF incur excess operative mortality rates, postoperative mortality rates, and congestive heart failure after AVR. However, postoperative EF improves markedly, and most patients enjoy a long postoperative survival without recurrence of heart failure after AVR; thus they should not be denied the benefits of AVR.

Purpose: We sought to determine the importance of a third heart sound (S(3)) and its relation to hemodynamic and valvular dysfunction., Subjects and Methods: We prospectively enrolled 580 patients who had isolated valvular regurgitation (mitral, n = 299; aortic, n = 121) or primary left ventricular dysfunction with or without functional mitral regurgitation (n = 160). We analyzed the associations between the clinical finding of an audible S(3) (as noted in routine clinical practice by internal medicine physicians) and hemodynamic alterations measured by comprehensive quantitative Doppler echocardiography., Results: S(3) was more prevalent in patients with primary left ventricular dysfunction (46%, n = 73) than in organic mitral (16%, n = 47) or aortic (12%, n = 14) regurgitation (P <0.001). Patients with an S(3) were more likely to have class III-IV symptoms (55% [74 of 137] vs. 18% [80 of 443] of those without an S(3), P <0.001) and had a higher mean [+/- SD] pulmonary pressure (55 +/- 15 vs. 41 +/- 11 mm Hg, P <0.001). An S(3) was also related to a higher early filling velocity due to a greater filling volume, restrictive filling, or both. An S(3) was a marker of severe regurgitation (regurgitant fraction > or =40%) in patients with primary left ventricular dysfunction (odds ratio [OR] = 2.4; 95% confidence interval [CI]: 1.1 to 5.5), mitral regurgitation (OR = 17; 95% CI: 5.8 to 52), and aortic regurgitation (OR = 7.1; 95% CI: 1.8-28). An S(3) was also associated with restrictive filling in primary left ventricular dysfunction (OR = 3.0; 95% CI, 1.6 to 5.9), marked dilatation in mitral regurgitation (OR = 20; 95% CI: 6.8 to 58), and an ejection fraction (<50%) in aortic regurgitation (OR = 19; 95% CI: 6.0 to 62)., Conclusion: An audible S(3) is an important clinical finding, indicating severe hemodynamic alterations, and should lead to a comprehensive assessment and consideration of vigorous medical or surgical treatment.

Background: The width of the vena contracta (VC-W), the smallest area of regurgitant flow, reflects the degree of valvular regurgitation and is measurable by color Doppler imaging, but this method has not been validated in aortic regurgitation (AR)., Methods and Results: We prospectively examined 79 patients with isolated AR and 80 patients without regurgitation. The VC-W was measured from the long-axis parasternal view and compared with 2 simultaneous reference methods (quantitative Doppler and 2D echocardiography). In patients without regurgitation, the agreement between methods was excellent. In patients with AR, good correlations (all P<0.0001) were obtained between VC-W and effective regurgitant orifice (ERO) area and regurgitant volume recorded by quantitative Doppler (r=0.89 and 0.90, respectively) and 2D echocardiographic (r=0.90 and 0.89, respectively) methods. These correlations were similar with eccentric or central jets (all P>0.60). The other methods used showed good correlations of VC-W with aortographic grading of AR (n=8, r=0.82, P=0.01), with the proximal flow convergence method (n=53, r=0.85, P<0.0001), and with left ventricular end-diastolic volume (r=0.81, P<0.0001). Sensitivity and specificity of VC-W >/=6 mm for diagnosing severe AR (ERO >/=30 mm(2)) were 95% and 90%, respectively., Conclusions: For assessment of the degree of AR, VC-W shows good correlations with simultaneous quantitative measures (regardless of jet direction), shows good correlations with other methods of assessment of AR, and provides a high diagnostic value for severe AR. VC-W is a simple, reliable method that can be used clinically as part of comprehensive Doppler echocardiographic assessment of AR.

Background: The outcome of aortic regurgitation conservatively followed in clinical practice is poorly defined., Methods and Results: Long-term outcome of 246 patients with severe or moderately severe aortic regurgitation diagnosed by color Doppler echocardiography was analyzed. With conservative management, mortality rate was higher than expected (at 10 years, 34+/-5%, P<0. 001) and morbidity was high (10-year rates of 47+/-6% for heart failure and 62+/-4% for aortic valve surgery). At 10 years, 75+/-3% of patients had died or had surgery and 83+/-3% had had cardiovascular events. In multivariate analysis, predictors of survival were age (P<0.001), functional class (P<0.001), comorbidity index (P=0.033), atrial fibrillation (P=0.002), and left ventricular end-systolic diameter corrected for body surface area (P=0.025). Ejection fraction was also an independent predictor of overall survival, including postoperative follow-up of surgically treated patients (P<0.001). High risk during conservative treatment, with mortality rate in excess of that expected, was noted among patients with severe, even transient, symptoms (24.6% yearly, P<0.001) but also in those with mild (class II) symptoms (6.3% yearly, P=0.02) and in asymptomatic patients with left ventricular ejection fraction <55% (5.8% yearly, P=0.03) or with end-systolic diameter normalized to body surface area >/=25 mm/m2 (7.8% yearly, P=0.004). Surgery performed during follow-up was independently associated with reduced cardiovascular mortality (adjusted hazard ratio, 0.54; P=0.048)., Conclusions: Patients diagnosed with severe aortic regurgitation in clinical practice incur excess mortality and high morbidity, underscoring the serious prognosis of the disease. Surgery, which reduces cardiac mortality rates, should be considered promptly in high-risk patients.

Objectives: We sought to determine the reliability of the proximal isovelocity surface area (PISA) method for calculation of effective regurgitant orifice (ERO) of aortic regurgitation (AR)., Background: The ERO area can be calculated by the PISA method, but this method has not been validated in AR., Methods: ERO calculation by the PISA method was undertaken prospectively in 71 consecutive patients with isolated AR and achieved in 64 and compared with two simultaneous reference methods (quantitative Doppler and quantitative two-dimensional echocardiography). In addition, this method was compared with angiography in 12 patients, with surgical assessment in 18 patients and with ventricular volumes in all patients., Results: Good correlations between PISA and reference methods were obtained (both r=0.90, both p < 0.0001), but a trend toward underestimation of the ERO by the PISA method was noted (24+/-19 vs. 26+/-22 mm2 and 27+/-23 mm2, respectively, both p=0.04). However, this trend was confined to five patients with an obtuse flow convergence angle (>220 degrees), and on multivariate analysis this variable was the only independent determinant of underestimation of the ERO. In contrast, in 59 patients with a flat flow convergence (< or =220 degrees ), the PISA method, in comparison with reference methods, showed excellent correlations, with a narrow standard error of the estimate (r=0.95, SEE 5.4 mm2, and r=0.95, SEE 5.8 mm2; all p < 0.0001) and no trend toward underestimation (22+/-18 vs. 23+/-16 mm2, p=0.44, and vs. 23+/-18 mm2, p=0.34)., Conclusions: In patients with AR, the PISA method can be used to measure the ERO with reasonable feasibility. Underestimation of the ERO by PISA may occur in patients with an obtuse flow convergence angle. However, in most patients with appropriate flow convergence, PISA provides reliable measurement of the ERO of AR.

Objectives: We sought to determine the independent effect of preoperative symptoms on survival after surgical correction of aortic regurgitation (AR)., Background: Aortic valve replacement for severe AR is recommended after New York Heart Association functional class III or IV symptoms develop. However, whether severe preoperative symptoms have a negative influence on postoperative survival remains controversial., Methods: Preoperative characteristics and postoperative survival in 161 patients with functional class I or II symptoms (group 1) were compared with those in 128 patients with class III or IV symptoms (group 2) undergoing surgical repair of severe isolated AR between 1980 and 1989., Results: Compared with group 1, group 2 patients were older (p < 0.0001), were more often female (p = 0.001) and more often had a history of hypertension (p = 0.001), diabetes mellitus (p = 0.029) or myocardial infarction (p = 0.005) and were more likely to require coronary artery bypass graft surgery (p < 0.0001). The operative mortality rate was higher in group 2 (7.8%) than in group 1 (1.2%, p = 0.005), and the 10-year postoperative survival rate was worse (45% +/- 5% [group 2] vs. 78% +/- 4% [group 1], p < 0.0001). Compared with age- and gender-matched control subjects, long-term postoperative survival was similar to that expected in group 1 (p = 0.14) but significantly worse in group 2 (p < 0.0001). On multivariate analysis, functional class III or IV symptoms were significant independent predictors of operative mortality (adjusted odds ratio 5.5, p = 0.036) and worse long-term postoperative survival (adjusted hazard ratio 1.81, p = 0.0091)., Conclusions: In the setting of severe AR, preoperative functional class III or IV symptoms are independent risk factors for excess immediate and long-term postoperative mortality. The presence of class II symptoms should be a strong incentive to consider immediate surgical correction of severe AR.

Background: Indications for surgical correction of aortic regurgitation have been established mostly in men and have not been validated in women. The outcome of this surgical correction in women is unknown., Methods and Results: Baseline characteristics and postoperative outcomes were compared between 51 women and 198 men undergoing surgery for isolated aortic regurgitation between 1980 and 1989. Compared with men, women had surgery rarely for severe left ventricular enlargement (systolic diameter > or = 55 mm in 11% versus 27%, P = .031; diastolic diameter > or = 80 mm in 0% versus 16%, P < .0001) and more often for class III to IV symptoms (59% versus 32%, P < .0001). Operative mortalities were similar in women and men (3.9% and 4.5%, respectively). Among operative survivors, 10-year survival was worse for women than for men (39 +/- 9% versus 72 +/- 4%, P = .0002) and, in contrast with men, was worse than expected for women (P < .0001). Independent predictors of late survival were different for men (age and ejection fraction) and women (age and concomitant coronary bypass grafting). By multivariate analysis, female sex was an independent predictor of worse late survival (adjusted relative risk, 1.80; 95% CI, 1.04 to 3.11)., Conclusions: The generalization to women of the unadjusted left ventricular diameter surgical criteria established in men results in irrelevant criteria almost never reached in women, who often undergo surgery after developing severe symptoms. After surgery, women exhibit an excess late mortality, suggesting that surgical correction of aortic regurgitation should be considered at an earlier stage in women.

Objectives: This study sought to determine the outcome of aortic valve replacement for aortic regurgitation complicated by extreme left ventricular dilation., Background: Aortic valve replacement has been recommended in aortic regurgitation with extreme left ventricular dilation (diastolic dimension >/= 80 mm), but extreme left ventricular dilation raises concern about irreversible left ventricular dysfunction., Methods: Thirty-one patients with a preoperative echocardiographic diastolic dimension >/= 80 mm (group 1) undergoing operation for severe isolated aortic regurgitation between 1980 and 1989 were compared with 188 patients with a diastolic dimension <80 mm operated on during the same period (group 2)., Results: Preoperatively, extreme left ventricular dilation was seen only in male patients and was associated with a reduced ejection fraction (43 +/- 12% vs. 53 +/- 11% [mean +/- SD], p < 0.0001). The postoperative outcome of group 1 was compared with that of male patients in group 2 (group 2M, n = 144). The operative mortality rates for groups 1 and 2M were 0% and 5.6%, respectively (p = 0.35). Late survival in operative survivors was similar in groups 1 and 2M, but compared with expected survival, an excess mortality was observed for group 1 (p = 0.024). Preoperative ejection fraction, but not diastolic dimension, independently predicted late survival and postoperative ejection fraction. Postoperatively, groups 1 and 2M showed a similar improvement in ejection fraction, but persistent left ventricular enlargement was more frequent in group 1., Conclusions: Extreme left ventricular dilation due to aortic regurgitation is observed in male patients and is frequently associated preoperatively with a reduced ejection fraction but is not a marker of irreversible left ventricular dysfunction. Operative risk and late postoperative survival are acceptable in these patients, although a late excess mortality, predicted best by preoperative ejection fraction, is observed. Therefore, extreme left ventricular dilation is not a contraindication to operation, which should be performed before left ventricular dysfunction occurs.

Purpose: To evaluate the relationship between the intensity of murmurs and severity of mitral and aortic regurgitation., Patients and Methods: Consecutive patients with chronic isolated aortic (n = 40) or mitral (n = 170) regurgitation undergoing echocardiographic quantitation of regurgitation between 1990 and 1991 were studied. Regurgitant volume and fraction were measured using two simultaneous methods (quantitative Doppler echocardiography and quantitative two-dimensional echocardiography); the intensity of the regurgitant murmur (grade 0 to 6) was noted by physicians unaware of the study., Results: Correlations between murmur intensity and regurgitant volume and fraction were good in aortic regurgitation (r = .60 and r = .67, respectively; P < 0.001) and mitral regurgitation (r = .64 and r = .67, respectively; P < 0.001) but weaker (r = .47 and r = .45, respectively) in the subset of mitral regurgitation of ischemic or functional cause. Murmur intensity grades > or = 3 for aortic regurgitation and > or = 4 for mitral regurgitation predicted severe regurgitation (regurgitant fraction > or = 40%) in 71% and 91% of patients, respectively. Murmur grades < or = 1 for aortic regurgitation and < or = 2 for mitral regurgitation predicted "not severe" regurgitation in 100% and 88% of patients, respectively. Murmur grades 2 for aortic regurgitation and 3 for mitral regurgitation were not correlated to degree of regurgitation. The severity of regurgitation was the most powerful determinant of intensity of murmur., Conclusions: Murmur intensity correlates well with the degree of chronic organic aortic and mitral regurgitation, and can be used as a predictor of regurgitation severity and as a simple guideline for diagnostic testing in these patients.

Objectives: The purpose of this study was to determine the feasibility, relation to other methods and significance of the effective regurgitant orifice area measurement., Background: Assessment of the severity of valvular regurgitation (effective regurgitant orifice area) has not been implemented in clinical practice but can be made by Doppler echocardiography., Methods: Effective regurgitant orifice area was calculated by Doppler echocardiography as the ratio of regurgitant volume/regurgitant jet time-velocity integral and compared with color flow Doppler mapping, angiography, surgical classification, regurgitant fraction and variables of volume overload., Results: In 210 consecutive patients examined prospectively, feasibility improved from the early to the late experience (65% to 95%). Effective regurgitant orifice area was 28 +/- 23 mm2 (mean +/- SD) for aortic regurgitation (32 patients), 22 +/- 13 mm2 for ischemic/functional mitral regurgitation (50 patients) and 41 +/- 32 mm2 for organic mitral regurgitation (82 patients). Significant correlations were found between effective regurgitant orifice and mitral jet area by color flow Doppler mapping (r = 0.68 and r = 0.63, p < 0.0001, respectively) and angiographic grade (r = 0.77, p = 0.0004). Effective regurgitant orifice area in surgically determined moderate and severe lesions was markedly different in mitral regurgitation (35 +/- 12 and 75 +/- 33 mm2, respectively, p = 0.009) and in aortic regurgitation (21 +/- 8 and 38 +/- 5 mm2, respectively, p = 0.08). Strong correlations were found between effective regurgitant orifice area and variables reflecting volume overload. A logarithmic regression was found between effective regurgitant orifice area and regurgitant fraction, underlining the complementarity of these indexes., Conclusions: Calculation of effective regurgitant orifice area is a noninvasive Doppler development of an old hemodynamic concept, allowing assessment of the lesion severity of valvular regurgitation. Feasibility is excellent with experience. Effective regurgitant orifice area is an important and clinically significant index of regurgitation severity. It brings additive information to other quantitative indexes and its measurement should be implemented in the comprehensive assessment of valvular regurgitation.

Background: Quantitation of valvular regurgitation remains a challenge. The accuracy of quantitative Doppler is controversial, and its ability to measure regurgitant volume is unknown; therefore, it is not widely used., Methods and Results: In 120 patients (20 without regurgitation, 19 with aortic regurgitation, and 81 with mitral regurgitation), the stroke volume through the mitral annulus and left ventricular outflow tract were measured using pulsed-wave Doppler concurrently with left ventricular stroke volume calculated using left ventricular volumes measured by two-dimensional echocardiography Simpson's biapical method. Regurgitant volume and fraction were thus computed using Doppler or ventricular methods. In normal patients there were good correlations between Doppler and left ventricular measurements of stroke volume. Doppler regurgitant volume and fraction were 4.4 +/- 4.4 mL and 5.3 +/- 4.5%, respectively. In patients with aortic regurgitation, there were good correlations between Doppler and left ventricular measurements of stroke volume, regurgitant volume, and regurgitant fraction (r = 0.97, r = 0.95, and r = 0.93, respectively; p < 0.0001). In patients with mitral regurgitation, despite good correlations between Doppler and ventricular methods for stroke volume, regurgitant volume, and regurgitant fraction (r = 0.94, r = 0.93, and r = 0.94, respectively; p < 0.001), these variables were overestimated by Doppler. However, in the last 54 patients compared with the first 27, overestimation decreased significantly for regurgitant volume (5 +/- 10 mL versus 18 +/- 27 mL, p < 0.05) and regurgitant fraction (3.3 +/- 6.7% versus 6.2 +/- 6.8%, p = 0.05)., Conclusions: Quantitative Doppler can be performed in large numbers of patients in a clinical laboratory. Its potential limitation was identified as overestimation of mitral regurgitation, which is overcome with increased experience. Its achieved accuracy in mitral and aortic regurgitation allows measurement not only of regurgitant fraction but most importantly of regurgitant volume.