Chronic Aortic Regurgitation Research Articles

Percutaneous valved stent implantation in the ascending aorta for the treatment of very high-risk aortic regurgitation: an animal study

PurposeWe investigated the effects of percutaneous valved stent implantation in the ascending aorta as an alternative treatment for aortic regurgitation in a canine model. Materials and methodsA total of 16 healthy dogs weighing an average of 18.3 ± 2.1 kg were used for the establishment of animal models of chronic aortic regurgitation by percutaneous aortic valve perforation and balloon dilation. At 2 mo after successful model establishment, all experimental animals underwent valved stent implantation in the ascending aorta and then were followed up for 3 mo. ResultsExperimental models of chronic aortic regurgitation were successfully established in 10 dogs. Surviving dogs underwent successful valved stent implantation in the ascending aorta and were subsequently followed up for 3 mo. The level of instantaneous aortic regurgitation at 3-mo follow-up was significantly reduced compared with that before valved stent implantation (2.4 ± 0.9 versus 10.6 ± 2.1 mL/s, P < 0.05). The left ventricular ejection fraction was significantly increased (53.8 ± 4.2% versus 37.8 ± 3.7%, P < 0.05), and the left ventricular end-diastolic volume was also significantly reduced (30.3 ± 2.2 versus 40.1 ± 3.6 mL, P < 0.05). No paravalvular leak, stroke, atrioventricular block, or other complications occurred in dogs undergoing valved stent implantation. ConclusionsPercutaneous valved stent implantation in the ascending aorta is feasible, effective, and safe as an alternative treatment for very high-risk aortic regurgitation in a canine model.

An unusual complication of infective endocarditis: left ventricular outflow tract perforation

A 24-year-old female was admitted to our hospital complaining of fever, chest pain, cough and dyspnoea. Physical examination revealed tachycardia with heart rate 115 bpm, dull and decreased respiratory sounds in the lower left lung field, systolodiastolic murmur at the aortic and mesocardiac area. Chest X-ray showed an increased cardiothoracic ratio and left-sided pleural effusion. The erythrocyte sedimentation rate was found to be 64 mm/h. Echocardiography revealed moderate aortic insufficiency. Pathological flow was detected at left ventricular outflow tract (LVOT) by Doppler imaging. LV free wall was seen to be compressed partially by the haematoma surrounding the heart. Chest computed tomography (CT) showed the perforation at LVOT, partial compression of LV lateral wall, main pulmonary artery, superior vena cava, and nearly complete obstruction of left pulmonary veins (Figs. 1–3). The patient underwent emergent cardiac surgery. A pseudoaneurysm sac was detected starting from the lateral side of the aorta extending through transverse sinus and including the left anterior descending coronary artery region. Aortotomy was performed. The aortic valve was detected to be bicuspid. A perforation with a diameter of 10 × 15 mm was seen just below the aortic valve (Fig. 4). The perforation was repaired with a dacron graft, and aortic valve replacement was performed. The pathological examination revealed inflammation and vegetation at the sample taken from the perforation region, which demonstrated that the aetiology of perforation was mural infective endocarditis. Mural endocarditis is an inflammation and disruption of the nonvalvular endocardial surface of the cardiac chambers. Mural endocarditis may develop on LVOT secondary to chronic aortic regurgitation due to chronic endocardial trauma. Traumatised endocardium provides a nidus for the development of bacterial vegetation. It is well known that inflammation and vegetation may cause destructive lesions and perforation usually affecting valves, and result in acute valvular regurgitation, or may result in fistula formation. But myocardial perforation and pseudoaneurysm formation has rarely been reported. Excision of the pseudoaneurysm with LV reconstruction should be the treatment of choice in patients presenting with myocardial perforation and pseudoaneurysm formation.

Impact of aortic valve calcification severity and impaired left ventricular function on 3-year results of patients undergoing transcatheter aortic valve replacement

To evaluate clinical pre-interventional predictors of 3-year outcome and mortality in high-risk patients with severe aortic valve stenosis treated with transcatheter aortic valve implantation (TAVI). Among 367 patients included in the Aachen TAVI registry, 76 patients with baseline dual-source computed tomography (DSCT) for the quantification of aortic valve calcification (AVC) and a 3-year follow-up were identified. Survival at 30 days was 91 %, and it was 75 %, 66 % and 64 % at 1, 2 years and 3 years, respectively. Non-survivors at 3 years showed a significantly higher Agatston AVC score (2,854 ± 1,651) than survivors (1,854 ± 961, P = 0.007). Multivariate analysis including age, logistic EuroScore, glomerular filtration rate, Agatston AVC score, ejection fraction < 40 %, NYHA class, baseline medication, chronic lung disease and aortic regurgitation revealed that only the Agatston AVC score (P = 0.03) and impaired left ventricular function (P = 0.001) was significantly associated with mortality. Patients with Agatston AVC scores >2,000 had a significantly lower 3-year survival rate compared with patients with scores <2,000 (47 % vs 79 %, P = 0.004). In patients referred for TAVI, aortic valve calcification severity and impaired left ventricular function may serve as a predictor of long-term mortality. Therefore, AVC scores easily determined from pre-procedural CT datasets may be used for patient risk stratification.

Subclinical Myocardial Deformation Abnormalities in Asymptomatic Patients with Moderate to Severe Aortic Regurgitation: A Combined Tissue Doppler and Strain Rate Imaging Study

Background: Early detection of myocardial contractility disturbances in patients with asymptomatic moderate to severe aortic regurgitation (AR) leads to the early operative intervention early enough to prevent from poor postoperative heart failure (HF) prognosis. Objective: Our aim was to study the subclinical left ventricular (LV) dysfunction, by novel echocardiographic methods, myocardial deformation indices in patients with asymptomatic, and significant aortic regurgitation (AR). Patients and Methods: Standard echocardiogram and complementary tissue Doppler imaging (TDI) and Doppler based strain and strain rate (S/SR) imaging were performed in 44 asymptomatic patients with pure and significant AR and ejection fraction (EF) more than 50% (mean age:49.9 ± 17.2 years, 50% male) and 20 healthy participants (mean age: 47.3 ± 13.8 years, 65% male). In addition to TDI velocities to investigate the LV longitudinal deformation, peak systolic S and SR were measured at septal, lateral and posterior walls. The LV modified myocardial performance index (MPI) or Tie index also were calculated via TDI study. Results: AR group had significantly increased LV end systolic and end diastolic volumes, interventricular septum and posterior wall thickness compared to controls. In AR, Sm and Em of septal wall, Sm of lateral wall; S and SR of both septal and lateral walls were significantly decreased while MPI were significantly increased compared to healthy participants. Conclusions: Our results demonstrated the ability of PW-TDI and S/SR modalities in detection of the early subclinical abnormalities in asymptomatic patients with significant chronic AR.

Contribution of cardiopulmonary exercise testing to the identification of latent systolic dysfunction in chronic aortic regurgitation

Chronic aortic regurgitation (AR) is a valvulopathy of slow and insidious evolution, and patients may remain asymptomatic for a long period of time. Exercise-induced systolic dysfunction occurs during the natural history of chronic AR and is related to changes in both preload and afterload. We describe the case of a 58-year-old woman with a diagnosis of chronic AR who reported progressive dyspnea of six years’ duration. A cardiopulmonary exercise test to assess functional capacity showed flattening of both oxygen uptake and oxygen pulse curves, suggesting latent systolic dysfunction related to chronic AR, which was later confirmed by stress Doppler echocardiogram with dynamic physical exercise.

Contribution of cardiopulmonary exercise testing to the identification of latent systolic dysfunction in chronic aortic regurgitation

Chronic aortic regurgitation (AR) is a valvulopathy of slow and insidious evolution, and patients may remain asymptomatic for a long period of time. Exercise-induced systolic dysfunction occurs during the natural history of chronic AR and is related to changes in both preload and afterload. We describe the case of a 58-year-old woman with a diagnosis of chronic AR who reported progressive dyspnea of six years’ duration. A cardiopulmonary exercise test to assess functional capacity showed flattening of both oxygen uptake and oxygen pulse curves, suggesting latent systolic dysfunction related to chronic AR, which was later confirmed by stress Doppler echocardiogram with dynamic physical exercise.

ASSA13-15-21 Percutaneous Valved Stent Implantation in the Ascending Aorta For the Treatment Very High-Risk Aortic Regurgitation: An Animal Study

Objective We investigated the feasibility of percutaneous valved stent implantation in the ascending aorta as an alternative treatment for very high-risk elderly patients with aortic regurgitation. Methods A total of 16 healthy dogs weighing an average of 18.3 ± 2.1 kg were used for the establishment of animal models of chronic aortic regurgitation by percutaneous aortic valve perforation and balloon dilation. At 2 months after successful model establishment, all experimental animals underwent valved stent implantation in the ascending aorta, and then were followed up for 3 months. Results Experimental models of chronic aortic regurgitation were successfully established in 10 dogs. Survival dogs underwent successful valved stent implantation in the ascending aorta and were subsequently followed up for 3 months. The instantaneous aortic regurgitation at 3 months follow-up was significantly reduced as compared with the level before valved stent implantation (2.4 ± 0.9 vs. 10.6 ± 2.1 ml/s, P ejection fraction was significantly increased (53.8 ± 4.2 vs. 37.8 ± 3.7, P P Conclusions Percutaneous valved stent implantation in the ascending aorta is feasible, effective and safe as an alternative treatment for very high-risk elderly patients with aortic regurgitation.

Mitral Valve Enlargement in Chronic Aortic Regurgitation as a Compensatory Mechanism to Prevent Functional Mitral Regurgitation in the Dilated Left Ventricle

The aim of this study was to test the hypothesis that mitral valve (MV) enlargement occurring in chronic aortic regurgitation (AR) prevents functional mitral regurgitation (FMR). Chronic AR causes left ventricular (LV) dilation, creating the potential for FMR. However, FMR is typically absent during compensated AR despite substantial LV enlargement. Increased mitral leaflet area has been identified in AR, but it is unknown whether increased MV size can represent a compensatory mechanism capable of preventing FMR. Database review of 816 patients with at least moderate AR evaluated the prevalence of FMR. A total of 90 patients were enrolled prospectively for 3-dimensional echocardiography (30 AR, 30 FMR, and 30 controls) to assess MV geometry including total leaflet area. FMR was present in 5.6% of AR patients by database review. Prospectively, only 1 AR patient had more than mild FMR despite increased LV end-diastolic volume (82 ± 22, 86 ± 23, and 51 ± 12 cm(3)/m(2), respectively, for AR, FMR vs. control patients; p < 0.01) and similar sphericity index, annular area, and tethering distances compared with FMR. Total MV area was largest in AR (31.3% greater than normal), increasing significantly more than in FMR. The ratio of valve size to closure area was maintained in AR, whereas decreases in this ratio and LV ejection fraction independently predicted FMR. FMR prevalence is low in chronic AR. MV leaflet area is significantly increased compared with control and FMR patients, preserving a normal relationship to the area needed for closure in the dilated LV. Understanding the mechanisms underlying this adaptation could lead to new therapeutic interventions to prevent FMR.

102: Presence of hypertension impacts left ventricular remodeling and function in patients with aortic regurgitation. A speckle-tracking echocardiography study

Chronic aortic regurgitation is associated with a unique pattern of left ventricular (LV) volume and pressure overloading, leading to LV remodeling. Systolic hypertension is a characteristic of severe aortic regurgitation. Apical rotation is considered an effective noninvasive index of global LV function. To study the impact of hypertension on LV shape and mass and systolic and diastolic LV apical rotation assessed by speckle-tracking echocardiography (STE) in pts with chronic AR. We enrolled 27 patients (pts) with moderate-severe and severe chronic AR and 27 age- and gender-matched normal subjects. A comprehensive echocardiogram was performed in all pts. Systolic apical rotation and rotation rate and diastolic apical rotation rate were measured from two-dimensional greyscale LV parasternal apical short-axis images by STE. Global LV geometry was assessed using a sphericity index defined as LV end-diastolic volume divided by the volume of a sphere with the same diameter as the LV end-diastolic longitudinal length. Left ventricular EF was similar in both groups. Pts in AR group had higher LV diameters, volumes and mass (p<0.001). Peak systolic apical rotation was lower in the AR group (10.5±5.0 vs 18.0±6.2°, p<0.001). Peak diastolic apical rotation rate was also lower in the AR group (-81.8±43.7 vs -106.9±35.8°/s, p=0.025). In a subgroup analysis of AR patients with or whitout hypertension (12 vs 15 pts) we found no difference in LV diameters, volumes and EF between subgroups but AR pts with hypertension tended to have a higher LV mass index (170±55 vs 133±23 g/m 2 , p=0.05) and a higher SI (0.46±0.1 vs 0.37±0.07, p=0.039). Peak systolic apical rotation (7.9±4.7 vs 12.5±4.5°, p=0.015) and peak diastolic apical rotation rate (-55.4±33.0 vs -102.9± 40.3°/s, p=0.003) were lower in AR pts with hypertension. Hypertension impacts not only LV mass but especially shape and systolic and diastolic LV function in pts with significant chronic AR.

Exercise Echocardiography in Asymptomatic or Minimally Symptomatic Chronic Severe Aortic Regurgitation

Exercise Echocardiography in Asymptomatic or Minimally Symptomatic Chronic Severe Aortic Regurgitation

Contractile Reserve Determined on Exercise Echocardiography in Patients With Severe Aortic Regurgitation

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. 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 (-). 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.

Prospective Comparison of Valve Regurgitation Quantitation by Cardiac Magnetic Resonance Imaging and Transthoracic Echocardiography

Both transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) imaging allow quantification of chronic aortic regurgitation (AR) and mitral regurgitation (MR). We hypothesized that CMR measurement of regurgitant volume (RVol) is more reproducible than TTE. TTE and CMR performed on the same day in 57 prospectively enrolled adults (31 with AR, 26 with MR) were measured by 2 independent physicians. TTE RVol(AR) was calculated as Doppler left ventricular outflow minus inflow stroke volume. RVol(MR) was calculated by both the proximal isovelocity surface area method and Doppler volume flow at 2 sites. CMR RVol(AR) was calculated by phase-contrast velocity mapping at the aortic sinuses and RVol(MR) as total left ventricular minus forward stroke volume. Intraobserver and interobserver variabilities were similar. For AR, the Bland-Altman mean interobserver difference in RVol was -0.7 mL (95% confidence interval [CI], -5 to 4) for CMR and -9 mL (95% CI, -53 to -36) for TTE. The Pearson correlation was higher (P=0.001) between CMR (0.99) than TTE readers (0.89). For MR, the Bland-Altman mean difference in RVol between observers was -4 mL (95% CI, -21 to 13) for CMR compared with 0.7 mL (95% CI, -30 to 32) for the proximal isovelocity surface area and -10 mL (95% CI, -76 to 56) for TTE volume flow at 2 sites. Correlation was similar for CMR (0.94) versus TTE readers (0.90 for the proximal isovelocity surface area). Compared with TTE, CMR has lower intraobserver and interobserver variabilities for RVol(AR), suggesting CMR may be superior for serial measurements. Although RVol(MR) is similar by TTE and CMR, variability in measured RVol by both approaches suggests that caution is needed in clinical practice.

The predictive value of DE-CMR in patients with severe chronic aortic regurgitation and extremely dilated left ventricular chamber

To determine whether preoperative contrast delay-enhanced cardiovascular magnetic resonance imaging (DE-CMR) could help predict long-term survival of patients with severe chronic aortic regurgitation and extremely dilated left ventricular chamber after aortic valve replacement. Totally 37 patients enrolled between February 2008 and November 2010 with severe chronic aortic regurgitation and extremely dilated left ventricular chamber, who met the echo criteria, that was left ventricular end diastolic dimension > 70 mm or left ventricular end systolic dimension > 55 mm, and were scheduled to the surgery. The 2-dimensional echocardiographic examinations and CMR with late gadolinium-enhancement (LGE) were performed routinely preoperatively. According to the results of CMR, the patients were divided into 2 groups: the LGE positive(+) group and LGE negative(-) group. The association of LGE with event free survival, postoperative cardiac function and postoperative hospital stay time was investigated. Fifteen patients had significant LGE signals in CMR films, while the other twenty-two were silent. All of them received the operative procedures, including aortic valve replacement in 28 cases, Bentall procedure in 3 cases, aortic valve replacement and ascending aorta replacement in 6 cases, and concomitant mitral valve repair in 11 cases. Over a follow-up of 33.6 months, 1-year, 2-year and 3-year event free survival rates in LGE(-) group were 94.7%, 88.4%, and 72.6%, respectively, compared to 80.0%, 48.9%, and 32.6%, respectively in LGE(+) group (χ(2) = 7.244, P = 0.007). The postoperative hospital stay time of LGE(-) group was (9 ± 2) days, which of LGE(+) group was (10 ± 3) days (t = 1.175, P = 0.248). LGE positive signal in CMR films is a potential predictor of persistent cardiac failure after aortic valve replacement for patients with severe chronic aortic regurgitation and extremely dilated left ventricular chamber. It has intimate relationship with malignant arrhythmia and sudden death, which makes it a valuable technique in preoperative evaluation and risk stratification.

Echocardiographic Predictors of Left Ventricular Dysfunction after Aortic Valve Surgery in Children with Chronic Aortic Regurgitation

Postoperative left ventricular dysfunction is associated with poor prognosis in adults with severe chronic aortic regurgitation and published practice guidelines aim to minimize this risk. However, only limited information exists in pediatrics. The goal of this study was to define preoperative risk factors for postoperative left ventricular dysfunction in children with chronic aortic regurgitation. Patients fulfilling the following criteria were included in this study: (1) age at preoperative echocardiogram ≤18 years; (2) ≥moderate aortic regurgitation; (3) ≤mild aortic valve stenosis; (4) no additional valve disease/shunt; (5) underwent aortic valve surgery for aortic regurgitation; and (6) available preoperative and ≥6-month postoperative echocardiograms with adequate information. Primary outcome was postoperative left ventricular dysfunction defined as ejection fraction z-score < -2. Median ages at diagnosis and surgery of the 53 eligible patients were 6.9 (0.04-17.2) and 13 years (1.2-22.4), respectively. Compared with patients whose postoperative left ventricular ejection fraction was normal, those with left ventricular ejection fraction z-score < -2 (n = 10) had significantly higher preoperative left ventricular end-diastolic and systolic volumes and dimensions and lower indices of systolic function. Preoperative left ventricular ejection fraction z-score < -1 was the most sensitive (89%; confidence interval [CI] 52, 100) but least specific (58%; CI 41, 73), whereas left ventricular end-systolic diameter z-score ≥ 5 was the most specific (95%; CI 84, 99) but least sensitive (60%; CI 26, 88) outcome identifier. A combination of shortening fraction z-score < -1 or end-systolic diameter z-score ≥ 5 best identified postoperative left ventricular dysfunction with an area of 0.819 under the receiver-operator characteristic curve. Lower indices of left ventricular systolic function and severity of dilation identify children at risk for postoperative left ventricular dysfunction after aortic valve surgery. These identifiers are similar to predictors defined in adult patients albeit with different threshold values.

Combined aortic and mitral regurgitation - a scenario difficult to manage

Abstract Objectives The simultaneous presence of substantial regurgitation of both the aortic and the mitral valve imposes a massive volume load and, due to the aortic regurgitation, a pressure load on the left ventricle. This condition usually is caused by primary aortic regurgitation and concomitant functional mitral regurgitation due to left ventricular enlargement, but lesions can also be primary in both valves, as in endocarditis, carcinoid disease, or due to the cardiotoxicity of appetite-depressant drugs. Because dilatation of the left ventricle caused by chronic aortic regurgitation mostly is not fully reversible by aortic valve surgery, it is unlikely that severe or moderate mitral regurgitation will regress significantly after aortic valve surgery alone. In such cases, simultaneous repair of a severely regurgitant mitral valve is recommended by the guidelines, but the recommendation should probably be extended to moderate mitral regurgitation too. Conclusion In treating combined aortic and mitral regurgitation, the incomplete reversibility of left ventricular dilatation due to aortic regurgitation should be kept in mind. If indications for aortic valve replacement are fulfilled, concomitant mitral valve repair should be strongly considered.

High Transvalvular Gradients Across a Prosthetic Valve in the Mitral Position: Not Ignoring the Bigger Picture

High Transvalvular Gradients Across a Prosthetic Valve in the Mitral Position: Not Ignoring the Bigger Picture

Contemporary reviews by surgeon: timing of operation for chronic aortic regurgitation

The timing of operation for severe chronic and asymptomatic aortic regurgitation remains problematic, though the present trend is to prefer early surgery. In this article, we review recent reports, mainly published after 2006, regarding indications for surgical treatment for pure chronic AR.

Acute Aortic Regurgitation

Aortic regurgitation (AR) is characterized by regurgitation of blood from the aorta to the left ventricle (LV) during diastole and is attributable to diverse congenital and acquired abnormalities of the aortic valve or the wall of the aortic root. AR can be either chronic or acute. The classic features of chronic AR have been known to clinicians for nearly 2 centuries. Corrigan described chronic AR in 1832 in his text “On Permanent Patency of the Mouth of the Aorta, or Inadequacy of the Aortic Valves.”1 Patients with chronic AR remain asymptomatic for many years as the LV becomes gradually enlarged; cardiac symptoms and clinical congestive heart failure then develop. On the other hand, acute severe AR, if untreated, leads to advanced heart failure and early death. Acute severe AR may be difficult to recognize clinically and is often erroneously diagnosed as another acute condition such as sepsis, pneumonia, or nonvalvular heart disease. Acute or subacute infective endocarditis, aortic dissection, and aortic valve damage caused by trauma are known causes of acute AR. We present 2 cases of acute AR (case 1, infective endocarditis; case 2, Stanford type A aortic dissection), and we propose management plans for each case (Figure 1A and 1B). Figure 1. Proposed management plan for acute aortic regurgitation (AR) due to infective endocarditis ( A ) and aortic dissection ( B ). CHF indicates congestive heart failure; TTE, transthoracic echocardiogram; TEE, transesophageal echocardiogram; IE, infective endocarditis; AR, aortic regurgitation; PMVC, premature mitral valve closure; DMR, diastolic mitral regurgitation; ESMR, early systolic mitral regurgitation; ICU, intensive care unit; EKG, electrocardiogram; LVOT, left ventricular outflow tract; and AV, aortic valve. A 23-year-old man admitted to an intensive care unit with Staphylococcus bacteremia presented with soft heart sounds and a to-and-fro murmur, which progressed to a silent precordium within 24 hours. Bedside transthoracic …

Subendocardial dysfunction in patients with chronic severe aortic regurgitation and preserved ejection fraction detected with speckle-tracking strain imaging and transmural myocardial strain profile

It remains difficult to detect subtle left ventricular (LV) myocardial dysfunction in chronic aortic regurgitation (AR) patients with the preserved ejection fraction (EF). We studied 36 chronic severe AR patients undergoing surgical correction with the EF of 58 ± 6% (all ≥ 50%). Echocardiography was performed before and 12 ± 8 months after surgical correction. We used two-dimensional speckle-tracking strain imaging to evaluate global radial strain in the inner-half (GRSinner), outer-half (GRSouter), and total (GRStotal) layer from the mid-LV short-axis view. We also evaluated the transmural strain profile in the LV posterior wall by using myocardial tissue Doppler radial strain, and the location of peak strain was determined as the percentage of the distance from the endocardium to the epicardium accounted for by the wall thickness. Fifteen EF-matched normal volunteers were studied for comparison. GRSinner for AR patients was significantly smaller than that for controls (28.9 ± 12.9 vs. 37.1 ± 9.1%, P = 0.032), and the location of peak strain had significantly shifted to the epicardial side compared with that in controls (27.1 ± 14.0-13.2 ± 4.8%, P = 0.001). In contrast, GRStotal and GRSouter were similar for the two groups. After surgical correction, EF increased from 58 ± 6 to 62 ± 7% (P = 0.018), GRSinner from 27.8 ± 12.5 to 37.7 ± 14.6% (P < 0.0001), and the location of peak strain significantly shifted to the endocardial side (26.9 ± 13.9-19.1 ± 11.9%, P = 0.028). However, GRStotal and GRSouter did not change. The LV endocardium side, impaired in chronic AR patients with the preserved EF, improved after surgical correction. Our observations may prove useful for evaluating subtle early changes in such patients.

Favorable Effects of Vasodilators on Left Ventricular Remodeling in Asymptomatic Patients With Chronic Moderate‐Severe Aortic Regurgitation and Normal Ejection Fraction: A Meta‐Analysis of Clinical Trials

The role of vasodilator therapy in asymptomatic patients with chronic moderate to severe aortic regurgitation (AR) and normal left ventricular (LV) function is uncertain. We assessed the effects of vasodilator therapy (hydralazine, calcium channel blockers, and angiotensin-converting enzyme inhibitors) in this subgroup of patient population. Vasodilators have favorable effects on LV remodelling in asymptomatic patients with chronic moderate to severe aortic regurgitation and normal LV function. We performed a systematic literature search for randomized clinical trials using long-term vasodilator therapy in asymptomatic patients with chronic severe AR and normal LV function. The magnitude of difference between the vasodilator and nonvasodilator groups was assessed by computing the mean difference (MD). Heterogeneity of the studies was analyzed by Cochran Q statistics. The MD for LV ejection fraction, LV end systolic volume index, and LV end diastolic volume index were computed by random effects model. The MD for LV end-systolic diameter and LV end-diastolic diameter were computed by fixed effects model. A 2-sided alpha error <0.05 was considered to be statistically significant. Seven studies with 460 patients were included. Meta-analysis of the studies revealed a significant increase in LVEF (MD: 5.32, 95% confidence interval [CI]: 0.37 to 10.26, P = 0.035), a significant decrease in LV end diastolic volume index (MD: -16.282, 95% CI: -23.684 to -8.881, P < 0.001), and a significant decrease in LV end diastolic diameter (MD: -2.343, 95% CI: -3.397 to -1.288, P < 0.001) in the vasodilator group compared with the nonvasodilator group. However, there was no significant decrease in LV end systolic volume index (MD: -6.105, 95% CI: -12.478 to 0.267, P = 0.060) or in LV end systolic diameter (MD: 0.00, 95% CI: -0.986 to 0.986, P = 1.0) in the vasodilator group compared with the nonvasodilator group. In asymptomatic patients with chronic severe AR and normal LV function, vasodilators have favorable effects on LV remodeling.