From The New York Hospital–Cornell Medical Center, New York, NY. Dr
Aschermann is currently at the Department of Medicine, Charles University,
Prague, The Czech Republic.
Background—Optimal criteria for
valve replacement are unclear in asymptomatic/minimally
symptomatic patients with aortic
regurgitation (AR) and normal left
ventricular (LV) performance at rest. Moreover,
previous studies have not assessed the prognostic capacity of
load-adjusted LV performance
("contractility") variables, which may be
fundamentally related to clinical state. Therefore, 18 years ago, we
set out to test prospectively the hypothesis that objective noninvasive
measures of LV size and performance and, specifically, of
load-adjusted variables, assessed at rest and during exercise (ex),
could predict the development of currently accepted indications for
operation for AR.
Methods and Results—Clinical variables and measures of LV
size, performance, and end-systolic wall stress (ESS)
were assessed annually in 104 patients by radionuclide cineangiography
at rest and maximal ex and by echocardiography at
rest; ESS was derived during ex. During an average 7.3-year follow-up
among patients who had not been operated on, 39 of 104 patients either
died suddenly (n=4) or developed operable symptoms only (n=22) or
subnormal LV performance with or without symptoms (n=13)
(progression rate=6.2%/y). By multivariate Cox model
analysis, change (
Conclusions—Currently accepted symptom and LV performance
indications for valve replacement, as well as sudden cardiac death, can
be predicted in asymptomatic/minimally
symptomatic patients with AR by load-adjusted
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Prediction of Indications for Valve Replacement Among Asymptomatic or Minimally Symptomatic Patients With Chronic Aortic Regurgitation and Normal Left Ventricular Performance
) in LV ejection fraction (EF) from rest
to ex, normalized for ESS from rest to ex (LVEF-ESS index),
was the strongest predictor of progression to any end point or to
sudden cardiac death alone. Unadjusted LVEF was almost as efficient.
Symptom status modified prediction on the basis of the LVEF-ESS
index. The population tercile at highest risk by LVEF-ESS
progressed to end points at a rate of 13.3%/y, and the lowest-risk
tercile progressed at 1.8%/y. LVEF-ESS index, which includes data obtained during exercise.
Key Words: valves • heart failure • regurgitation • ventricles
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