Aortic Valve Replacement for the Asymptomatic Patient With Aortic Regurgitation
A New Piece of the Strategic Puzzle
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For patients with hemodynamically severe aortic regurgitation (AR), the primary remedial therapy is surgical aortic valve replacement (AVR). Timing of surgery, however, is a moving target. Techniques and prosthetic devices continually improve, justifying AVR progressively earlier in the natural history of the disease. Indeed, there is currently a general consensus that surgery for AR is appropriate when congestive symptoms first appear, even if they are mild.1 This philosophy represents a distinct departure from the accepted standard of a generation ago, when the symptomatic indication for AVR was New York Heart Association functional class III. For asymptomatic patients, AVR remains controversial, except when left ventricular (LV) systolic performance is subnormal at rest as judged from ejection fraction (EF, or the parallel echocardiographic measure of fractional shortening [FS]). This standard was first suggested by Henry et al,2,3⇓ who began a prospective echocardiographic and clinical assessment of patients with AR in 1972. Henry et al tested two hypotheses: first, that outcome after AVR is dependent on LV systolic performance, and second, that progression to symptoms is predictable when performance is subnormal in asymptomatic patients.
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The patients of Henry et al underwent AVR only when symptoms developed.2 If, by that time, FS at rest was subnormal, long-term postoperative survival averaged approximately 45% at 4 years after operation, compared with 90% if FS was normal pre-AVR. Although the point estimates were confounded in some of their 49 patients by concomitant mild aortic stenosis or by coronary artery bypass grafting, the importance of LV performance in predicting outcome was clear, as was the sharp outcome dichotomization associated with normal versus subnormal LV performance. The data of Henry et al soon were supported by those of Cunha et al,4 Forman, et al,5 and Greves et al.6 In …