Impact of 2021 ESC/EACTS surgical triggers on postoperative survival in aortic regurgitation: Insights from the AVIATOR registry

Abstract

Until 2021, the strongest guidelines on surgical correction of severe aortic regurgitation (AR) focused on the left ventricular systolic function (LVEF) and the presence of symptoms. However, those situations lead to an outcome penalty, even after surgical correction. Recommendations on left ventricular end-systolic diameter (LVESD) gained in strength in 2021 as ESC/EACTS guidelines upgraded them for a class I. Moreover, more inclusive threshold values are now recommended as a class IIb for patients at low surgical risk, reflecting the will to recommend surgery before developing heart failure and its consequences on post-operative outcome. We sought to evaluate the impact of each guideline trigger and their new threshold on postoperative survival in chronic and severe AR from a large multicentric international registry. AVIATOR is an international multicenter surgery registry for aortic valve surgery. We selected adult patients which were operated with a severe and chronic AR. Final study population was 1899 patients (49 ± 15 years, 85% male) in which 1443 (76%) had symptoms (NYHA > I), 494 (26%) had a reduced LVEF (≤ 50%) and 549 (29%) had a dilated left ventricle (LVESD > 50 mm or > 25 mm/m 2 ). Postoperative overall survival was evaluated over a median of 37 months and censored at 10 years to limit bias from possible reoperation. Twelve patients (0.6%) died postoperatively, and 68 within 10 years. By multivariable Cox analysis, presence of heart failure symptoms (HR 2.60; 95CI [1.20–5.66]; P = 0.016), and either LVESD >50 mm or >25 mm/m 2 (HR 1.64; 95%CI [1.05–2.55]; P = 0.029) predicted survival independently over and above age, female gender and bicuspid phenotype. Therefore, patients operated on when meeting class I trigger had worse survival (87 ± 2%) than patients operated on without meeting trigger (97 ± 2%, P < 0.01). However asymptomatic patients operated on when meeting new class IIb trigger (LVESD > 20 mm/m 2 or LVEF between 50–55%) had an excellent 10-year survival (97 ± 3%) ( Fig. 1 ). In severe AR, patients operated on when meeting class I triggers have postoperative survival penalty. Asymptomatic patients operated on earlier have better survival. This supports early surgery in AR as encouraged by the recent ESC/EACTS guidelines.