Concomitant Aortic Regurgitation Research Articles

Prevalence and outcomes of patients with discordant high gradient aortic stenosis

Abstract Background Conflicting prognostic results have been reported in patients with discordant high gradient aortic stenosis (DHG-AS, the combination of a mean pressure gradient ≥40 mmHg and an aortic valve area (AVA) >1cm² ). Moreover, existing studies only included selected patients without concomitant aortic regurgitation. Purpose We assessed the prevalence and survival of patients presenting with DHG-AS in an unselected group of consecutive patients presenting to the echocardiography laboratory of a tertiary referral center. Methods 3,547 adult patients with AVA ≤1.5cm² and peak aortic jet velocity ≥2.5m/s or mean gradient ≥25mmHg who presented between 2005 and 2015 were included. Baseline clinical and echocardiographic data, and, when available, aortic valve calcium score (AVC) were collected in an institutional database, with subsequent retrospective analysis. The primary endpoint was all cause mortality during follow-up. Results DHG-AS was observed in 163 patients (11.6% of all patients with a gradient ≥ 40mmHg). After adjustment for potential confounders, overall mortality rate of patients with DHG-AS was similar to that of concordant severe AS (AVA ≤1cm², mean gradient ≥40mmHg; CSev-AS) patients (N=1,243; HR: 0.98[0.68;-1.44]; p=0.91), and discordant low gradient-AS (AVA ≤1cm²; gradient <40 mmHg; HGDLG-AS) patients (N=1,131, HR: 0.85[0.58-1.26]; p=0.42), and was worse than that of concordant moderate AS (AVA >1.0cm², gradient <40mmHg; CMod-AS) patients (N=1,010; HR: 0.54[0.36-0.81]; p=0.003, Fig 1). After adjustment for aortic velocities, aortic regurgitation had no significant impact on survival. Calcium scoring was performed in 716 patients, including 40 patients with DHG-AS. AVC in DHG-AS was higher than in patients with CMod-AS and DLG-AS, and not significantly different from that of CSev-AS. The AVC ratio (AVC divided by the sex-specific thresholds) was higher in patients with DHG-AS as compared to both CMod-AS and DLG-AS patients (Fig 2). Conclusions DHG-AS is not uncommon. Although an AVA ≥1.0 cm² is often seen as reassuring and mistaken as moderate AS, a high-pressure gradient conveys a poor prognosis, whatever the AVA and independently of the presence of concomitant aortic regurgitation.

Concomitant Aortic Regurgitation is Associated With Worse Prognosis in all Severe Aortic Stenosis Phenotypes

Concomitant Aortic Regurgitation is Associated With Worse Prognosis in all Severe Aortic Stenosis Phenotypes

Association Between Aortic Valve Calcification and Severity of Concomitant Aortic Regurgitation in Patients With Severe Aortic Stenosis.

Patients with severe aortic stenosis (AS) frequently have concomitant aortic regurgitation (AR), but the association between aortic valvular calcification (AVC) and the severity of AR remains unclear. We retrospectively reviewed patients with severe AS who underwent transthoracic echocardiography and multidetector computed tomography (MDCT) within 1 month. The patients were divided into 3 groups according to the degree of concomitant AR. The association between AVC and the severity of concomitant AR was assessed in patients with severe AS. The study population consisted of 95 patients: 43 men and 52 women with a mean age of 82±7 years. Of the 95 patients with severe AS, 27 had no or trivial AR, 53 had mild AR, and 15 had moderate AR. The AVC score (AVCS) and AVC volume (AVCV) significantly increased as the severity of concomitant AR increased (P=0.014 for both), and similar findings were obtained for the AVCS and AVCV indexes (P=0.004 for both). The severity of AR correlated with AVCS and AVCV measured by MDCT in patients with severe AS. AVC may cause concomitant AR, leading to worsening of disease condition.

Prevalence and Outcomes of Patients With Discordant High-Gradient Aortic Stenosis

BackgroundConflicting prognostic results have been reported in patients with discordant high-gradient aortic stenosis ([DHG-AS] the combination of a mean pressure gradient ≥40 mm Hg and an aortic valve area [AVA] >1 cm2). Moreover, existing studies only included selected patients without concomitant aortic regurgitation. ObjectivesThe authors assessed the prevalence and survival of patients presenting with DHG-AS in an unselected group of consecutive patients presenting to the echocardiography laboratory of a tertiary referral center. MethodsA total of 3,547 adult patients with AVA ≤1.5 cm2 and peak aortic jet velocity ≥2.5 m/s or mean gradient ≥25 mm Hg who presented between 2005 and 2015 were included. Baseline clinical and echocardiographic data, and, when available, aortic valve calcium (AVC) score were collected in an institutional database, with subsequent retrospective analysis. The primary endpoint was all-cause mortality during follow-up. ResultsDHG-AS was observed in 163 patients (11.6% of patients with a high gradient). After adjustment for potential confounders, overall mortality rate of patients with DHG-AS was similar to that of patients with concordant severe aortic stenosis (HR: 0.98 [95% CI: 0.66-1.44]; P = 0.91), and patients with discordant low-gradient aortic stenosis (HR: 0.85 [95% CI: 0.58-1.26]; P = 0.42), and higher than concordant moderate aortic stenosis (HR: 0.54 [95% CI: 0.36-0.81]; P = 0.003). After adjustment for aortic velocities, aortic regurgitation had no significant impact on survival. AVC was higher than in patients with concordant moderate aortic stenosis and discordant low-gradient aortic stenosis, and not significantly different from that of concordant severe aortic stenosis. ConclusionsDHG-AS is not uncommon. Whereas AVA >1.0 cm2 is often seen as moderate aortic stenosis, a high-pressure gradient conveys a poor prognosis, whatever the AVA and the severity of concomitant aortic regurgitation.

Kiosk 6R-TB-06 - Total Regurgitant FBaction: A Novel CMR Parameter to Predict Outcomes in Patients with Concomitant Aortic and Mitral Regurgitation

Kiosk 6R-TB-06 - Total Regurgitant FBaction: A Novel CMR Parameter to Predict Outcomes in Patients with Concomitant Aortic and Mitral Regurgitation

Aortic regurgitation provokes phenotypic modulation of smooth muscle cells in the normal ascending aorta

BackgroundAortic complications are more likely to occur in patients with ascending aortic aneurysms and concomitant aortic regurgitation (AR). AR may have a negative influence on the aortic wall structure even in patients with tricuspid aortic valves and absence of aortic dilatation. It is unknown whether smooth muscle cell (SMC) changes are a feature of AR-associated aortic remodeling. MethodsNondilated aortic samples were harvested intraoperatively from individuals with normal aortic valves (n = 10) or those with either predominant aortic stenosis (AS) (n = 20) or AR (n = 35). Tissue from each patient was processed for immunohistochemistry or used for the extraction of medial SMCs. Tissue and cells were stained for markers of SMC contraction (alpha-smooth muscle actin), synthesis (vimentin) and senescence (p16INK4A and p21Cip1 [p16/p21]). Replicative capacity was analyzed in cultured SMCs from AS- and AR-associated aortas. A subanalysis compared SMCs from individuals with either tricuspid aortic valves or bicuspid aortic valves to evaluate the effect of aortic valve morphology. ResultsIn aortic tissue samples, AR was associated with decreased alpha-smooth muscle actin and increased vimentin, p16 and p21 compared with normal aortic valves and AS. In cell culture, SMCs from AR-aortas had decreased alpha-smooth muscle actin and increased vimentin compared with SMCs from AS-aortas. AR-associated SMCs had increased p16 and p21 expression, and they reached senescence earlier than SMCs from AS-aortas. In AR, SMC changes were more pronounced with the presence of a bicuspid aortic valve. ConclusionsAR itself negatively influences SMC phenotype in the ascending aortic wall. This AR-specific effect is independent of aortic diameter and aortic valve morphology, although it is more pronounced with bicuspid aortic valves. These findings provide insight into the mechanisms of AR-related aortic remodeling, and they provide a model for studying SMC-specific therapies in culture.

Prognostic utility of N-terminal pro B-type natriuretic peptide ratio in mixed aortic valve disease

ObjectiveWe aimed to assess the incremental prognostic value of N-terminal-pro-B-type natriuretic peptide (Nt-proBNP) for risk stratification in mixed aortic valve disease (MAVD) patients.MethodsWe included 556 (73±12 years, 37% women) consecutive...

Total regurgitant fraction to predict aortic valve surgery in patients with concomitant aortic and mitral regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Both aortic regurgitation (AR) and mitral regurgitation (MR) produce left ventricular (LV) volume overload (1). Current prognostic assessment of AR does not include the presence and magnitude of MR. Therefore, in patients with concomitant AR and MR we might be underestimating the future need of valve replacement surgery. Cardiac magnetic resonance (CMR) is a very precise tool to quantify LV volumes together with aortic and mitral regurgitant volumes. Combining data from cine and phase contrast sequences it is possible to obtain a set parameter: total regurgitant fraction (TRF). Purpose To describe the prognostic value of TRF in patients with concomitant AR and MR. Methods Patients with concomitant AR and MR with CMR studies were retrospectively recruited in three tertiary hospitals. Cases of at least moderate AR and any grade of MR were included in the analysis. Patients with indication of aortic valve surgery (symptoms, severe LV dilatation or reduced LV eyection fraction) in the moment of the CMR were excluded. Aortic regurgitant fraction (ARF) was calculated from the phase constrast data as the ratio of AR volume and LV forward volume. Mitral regurgitant Fraction (MRF) was calculated from the cine sequences as the ratio of the MR volume and the LV stroke volume (LVSV) . TRF was calculated as the ratio of mitral plus aortic regurgitant volumes and the LVSV (MRV+ARV/LVSV) Results 35 cases were analyzed, with a mean follow up period of 40 months. 9 patients developed indications of aortic valve surgery. TRF had an area under curve (AUC) to predict aortic valve surgery of 0.82, in opposite to aortic regurgitant fraction (ARF) which had an AUC of 0.75 (Figure 1) The optimum cutoff value of TRF and ARF to predict the need of surgery in our series were 38% and 27%, respectively. After 3 years of follow up 53% of patients with TRF > 38% had to be intervened (Figure 2A). In contrast, 32% of patients with ARF >27% had to be intervened (Figure 2B) Conclusion MR presence increases volume overload in patients with moderate or severe AR. TRF is a promising parameter to predict the need of aortic valve surgery in this patients

Outcomes of Transcatheter Aortic Valve Replacement in Patients With Concomitant Aortic Regurgitation

BackgroundThis study sought to evaluate outcomes of transcatheter aortic valve replacement (TAVR) in patients with moderate or greater aortic regurgitation (AR). MethodsThis was an observational study using an institutional database of TAVRs from November 2012 to April 2022. The study compared outcomes of TAVR in patients with isolated aortic stenosis (AS) vs patients with AS and concomitant AR (moderate or greater). Those patients with trace or mild AR were excluded. Clinical and echocardiographic outcomes were compared, with end points established by the Valve Academic Research Consortium 3. Kaplan-Meier survival estimation and Cox regression for mortality were performed. Competing-risk cumulative incidence estimates for heart failure readmissions were also compared. ResultsOf 3295 patients, 605 (53.4%) had severe AS with no AR and 529 (46.6%) had severe AS with moderate or severe AR. There were no significant differences in in-hospital mortality, length of stay, stroke, myocardial infarction, permanent pacemaker requirement, transfusion requirement, minor or major vascular complications, or 30-day readmissions between the 2 groups (P > .05). There were also no significant differences in annular dissection or rupture, coronary obstruction, or device embolization. Mean gradient and paravalvular leak rates at 30 days and 1 year were similar between the groups. Survival estimates were comparable, and, on multivariable Cox regression, mixed aortic valvular disease was not associated with an increased hazard of death as compared with isolated AS (hazard ratio, 1.01; 95% CI, 0.81-1.25; P = .962). Cumulative incidence estimates for heart failure readmissions were comparable between groups. ConclusionsTAVR can be safely performed in patients with mixed valvular disease, with outcomes comparable to those in isolated AS.

Fate of aortic regurgitation after isolated repair of ventricular septal defect with concomitant aortic regurgitation in children

ObjectivesThe aim of the study was to evaluate the course of aortic valve regurgitation in patients with preoperative aortic valve regurgitation and ventricular septal defect who underwent repair of the ventricular septal defect without aortic valve repair. MethodsA total of 37 consecutive patients with a ventricular septal defect and aortic regurgitation who underwent surgery between April 2007 and March 2016 were included in the study. Demographic, echocardiographic, operative, and clinical data were reviewed. Early and late mortality and morbidity were analyzed. Aortic regurgitation grade, left ventricular function, and dimensions were compared between the preoperative transesophageal echocardiography and postoperative transthoracic echocardiogram at last follow-up. Multivariate logistic regression analysis was performed to determine factors associated with improvement of aortic valve function. ResultsThere was no early or late mortality. No reoperations or reinterventions were required. A total of 17 patients had mild or greater aortic regurgitation preoperatively. Only 5 patients had mild or greater aortic regurgitation at follow-up of 4.3 years (0.5-10.1). Twenty-eight (76%) of the 37 patients showed an improvement in their aortic regurgitation grade. Left ventricular end-systolic and end-diastolic diameter z-scores were significantly lower at follow-up (P = .007 and P = .001, respectively). Multivariable logistic regression identified low preoperative left ventricular ejection fraction as the only predictor of nonimprovement of aortic regurgitation (95% confidence interval, 0.732-0.999, P = .002). ConclusionsRepair of a ventricular septal defect with accompanying aortic regurgitation can be performed with excellent results without surgical intervention on the aortic valve. Accompanying aortic regurgitation, especially trivial to mild, at the time of ventricular septal defect repair improves in the majority of cases. Low preoperative left ventricular ejection fraction is predictive of nonimprovement of aortic regurgitation grade.

Prediction of aortic valve regurgitation after continuous-flow left ventricular assist device implantation using artificial intelligence trained on acoustic spectra

Significant aortic regurgitation (AR) is a common complication after continuous-flow left ventricular assist device (LVAD) implantation. Using machine-learning algorithms, this study was designed to examine valuable predictors obtained from LVAD sound and to provide models for identifying AR. During a 2-year follow-up period of 13 patients with Jarvik2000 LVAD, sound signals were serially obtained from the chest wall above the LVAD using an electronic stethoscope for 1 min at 40,000 Hz, and echocardiography was simultaneously performed to confirm the presence of AR. Among the 245 echocardiographic and acoustic data collected, we found 26 episodes of significant AR, which we categorized as “present”; the other 219 episodes were characterized as “none”. Wavelet (time–frequency) analysis was applied to the LVAD sound and 19 feature vectors of instantaneous spectral components were extracted. Important variables for predicting AR were searched using an iterative forward selection method. Seventy-five percent of 245 episodes were randomly assigned as training data and the remaining as test data. Supervised machine learning for predicting concomitant AR involved an ensemble classifier and tenfold stratified cross-validation. Of the 19 features, the most useful variables for predicting concomitant AR were the amplitude of the first harmonic, LVAD rotational speed during intermittent low speed (ILS), and the variation in the amplitude during normal rotation and ILS. The predictive accuracy and area under the curve were 91% and 0.73, respectively. Machine learning, trained on the time–frequency acoustic spectra, provides a novel modality for detecting concomitant AR during follow-up after LVAD.

Fate of moderate aortic regurgitation after cardiac surgery

ObjectiveTo determine the prevalence of concomitant aortic regurgitation (AR) in cardiac surgery and the outcomes of treatment options. MethodsBetween April 2004 and June 2018, 3289 patients underwent coronary artery bypass, mitral valve, or aortic aneurysm surgery without aortic stenosis. AR was graded none/trivial (score = 0), mild (score = 1+), or moderate (score = 2+). Patients with untreated 2+ AR were compared with those with 0 or 1+ AR, and to those with 2+ AR who had aortic valve surgery. Thirty-day and late survival, echocardiography, and clinical outcomes were compared using propensity score matching. ResultsOne hundred thirty-eight patients (4.2%) had 2+ AR; and 45 (33%) received aortic valve repair (n = 9) or replacement (n = 36) in the treated group and were compared with 2765 untreated patients with 0 AR and 386 patients with 1+ AR. Valve surgery was more common with anatomic leaflet abnormalities: bicuspid aortic valve (9% vs 0%; P < .01), rheumatic valve disease (16% vs 3%; P < .01), and calcification (47% vs 27%; P = .021). In unadjusted analysis, lower preoperative AR grade was associated with increased 10-year survival (P < .001). At year 10, progression to more-than-moderate AR among moderate AR patients was 2.6% and late intervention rate was 3.1%. In the untreated 2+ AR group, on last follow-up echocardiogram, 58% had improvement in AR, 41% remained 2+, and only 1% progressed to severe AR. ConclusionsAortic valve surgery in select patients with concomitant moderate AR can be added with minimal added risk, but untreated AR does not influence long-term survival after cardiac surgery and rarely required late intervention.

Effect of concomitant aortic regurgitation on early hypoattenuated leaflet thickening after transcatheter aortic valve replacement in patients with symptomatic severe aortic stenosis

Identification of hypoattenuated leaflet thickening (HALT) and subacute leaflet thrombosis has become widely recognized. Patients with anatomical changes associated with moderate or greater aortic regurgitation (larger sinus of Valsalva and eccentric left ventricular remodeling) appear to have less HALT early postprocedure compared with those without. Further research on the risk factors including anatomical and hemodynamic variables should further our knowledge of these entities so we can better manage patient both pre and post TAVR.

33-year follow-up after valvular surgery for carcinoid heart disease

Abstract Background Valvular surgery for carcinoid heart disease (CaHD) has been found to improve long-term prognosis. Experience is limited and questions about single versus double-valve surgery as well as selection of prosthetic valves remain under debate. Purpose We reviewed the surgical experience after valvular surgery for CaHD in our institution, which is a national referral center. Methods We reviewed clinical records and echocardiograms. Perioperative death was defined as mortality within 30 days of operation. Results Sixty consecutive patients (32 men, 62±9 years) underwent valve surgery between 1986 and 2019, of whom 59/60 had an intestinal carcinoid disease with hepatic metastases. Mean time from diagnosis to heart surgery was 3.8±3.7 years. Preoperatively, 6 patients were in NYHA class I/II, the others were in class III or IV. All 60 surgical procedures involved tricuspid valve replacement (TVR). In 47 cases, the pulmonary valve was treated surgically: Early in the series, five patients underwent pulmonary valvotomy or commissurotomy, and more recently, 42 patients received pulmonary valve replacement (PVR). All valves were replaced with bioprostheses, except for one pulmonary homograft. Concomitant significant aortic and mitral regurgitation occurred in 2 patients who received quadruple valve replacement. Two re-operations were performed due to degeneration of bioprostheses. Mean hospital stay was 13±9 days. Overall 30-day mortality was 11.6% (n=7) but was reduced to 8.3% in the last decade. The overall median survival was 2.2 years. Maximal survival free of reoperation was 18 years, and maximal survival for a single patient was 21 years. Median survival for combined TVR and PVR was significantly better than for single TVR or TVR combined with pulmonary valvotomy (3.0 years vs. 0.94 years, respectively, p=0.02; see Figure). Preoperatively, left ventricular ejection fraction (EF) was normal in 83%. Severe tricuspid regurgitation was always present. The right ventricle (RV) was dilated (RVD1 49 mm ± 5 mm) as well as the right atrium (60±16 ml/m2). The TAPSE was in normal range (17 to 29 mm). Pulmonary regurgitation was mild, moderate, severe, or indeterminate in 6%, 26%, 51%, and 17% respectively. In 17% the transpulmonary velocity was &amp;gt;2.5 m/s, indicating stenosis. On last available postoperative echo (mean time 2.1 years) EF was found unchanged. RV diameter was nearly normalized (RVD1 41 mm ± 5 mm). TAPSE was reduced (12 mm ± 4 mm). No significant regurgitation was detected in any TVR. There was significant stenosis (mean gradient &amp;gt;5 mmHg) in 23% of the TVR. No regurgitation of significance was detected in any PVR. A mean gradient &amp;gt;20 mmHg was found in 11% of the PVR. Conclusions While perioperative risk of valve replacement in CaHD remains substantial, this study shows relatively favourable outcomes of surgical valve replacement with bioprostheses. PVR together with TVR had better outcomes than those undergoing TVR only. Figure. Survival by Surgical Treatment. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Department of Medical Sciences, Uppsala University. Department of Surgical Sciences, Uppsala University

Effect of concomitant aortic regurgitation on early hypo-attenuated leaflet thickening after transcatheter aortic valve replacement in patients with symptomatic severe aortic stenosis.

We hypothesize that different degree of pre-existing aortic regurgitation (AR) may affect the presence of hypo-attenuated leaflet thickening (HALT) after transcatheter aortic valve replacement (TAVR). The mechanism of the presence of HALT post-TAVR is not fully understood. We retrospectively evaluated the post-procedural multi-slice computed tomography (MSCT) before discharge for evidence of HALT. Patients were grouped according to the degree of pre-existing AR. Baseline, native anatomy and procedure details were compared, then multivariate regression was performed. MSCT analyzed was performed at a median of 6 days post-TAVR in 179 patients. HALT was detected in 10.6% of patients. After adjusting for variables that were significantly different between groups, pre-existing ≥ moderate AR was protective to the risk of HALT (OR 0.15, 95% CI 0.03-0.84, p = .03). Stratifying for factors that might explain the impact of pre-existing AR on HALT, patients with a small Sinus of Valsalva, non-eccentric remodeling and receiving a large bioprosthesis experienced a sevenfold higher risk for HALT (OR 7.16, 95% CI 2.05-25.08, p = .002). Patients underwent TAVR with pre-existing ≥ moderate AR appeared to experience a lower incidence of early HALT compared to those patients with less than moderate AR, which may be explained by a larger Sinus of Valsalva and a higher proportion of LV eccentric remodeling.

DOUBLE TROUBLE: CARDIOGENIC SHOCK SECONDARY TO SEVERE AORTIC VALVE INSUFFICIENCY ACROSS A BICUSPID VALVE AND SEVERE MITRAL VALVE REGURGITATION

Bicuspid aortic valve (BAV) is a common congenital defect. This is a unique case of a patient with concomitant severe aortic regurgitation across a BAV and severe mitral regurgitation, presenting in shock. 55-year-old male with known BAV but no follow-up for 6 years, presented with two days of

Unusual Suspect Causing Myocardial Infarction

An 84-year-old man with New York Heart Association functional class III/IV, due to prolapse of segment 2 of the anterior mitral valve leaflet with severe regurgitation as a result, was admitted for elective percutaneous edge-to-edge mitral valve repair. Significant coronary artery disease was ruled out previously. The left ventricular systolic function was normal with moderate concomitant aortic regurgitation. Mitral valve surgery was not considered a suitable option by the heart team due to frailty and a prohibitive surgical risk profile. The patient had an indication for transcatheter mitral-leaflet approximation, using the MitraClip-NT device (Abbott Vascular, Abbott Park, IL, USA). Implantation of the first clip resulted in insufficient reduction of mitral regurgitation. Therefore, a second device was positioned. Within minutes after release, transesophageal ultrasonography showed single leaflet device attachment of the second device, necessitating the deployment of a third device in order to stabilize the flailing clip (Figure 1a). Although regurgitation was reduced to moderate hereafter, flailing of the second device persisted. Two days later, the patient developed severe chest pain and cardiogenic shock. Electrocardiography showed ST-elevation in the inferior leads, corresponding to acute inferior wall myocardial infarction. Coronary angiography showed a dislodged clip seated in the right coronary ostium (Figure 1b). A 24Fr sheath was placed in the right femoral artery. After several attempts, a 35-mm Amplatz gooseneck snare was successfully positioned around the clip (Figure 1c). Subsequently, the device was retracted across the thoracic and abdominal aorta into the femoral sheath, which was successfully removed thereafter (Figure 1d). After the procedure, the patient was hemodynamically stable with normalization of the electrocardiogram. Transcatheter mitral-leaflet approximation using the MitraClip-NT device is used in high-risk patients with symptomatic mitral valve regurgitation. This unique case demonstrates an extremely rare complication of this procedure with a successful percutaneous solution. No potential conflict of interest was reported by the authors.

Prevalence and relevance of impaired left ventricular function in chronic moderate regurgitation of native aortic valves

Background: Reduced ejection fraction (EF) in chronic moderate aortic regurgitation (AR) could be either due to a late remodelling response after longstanding moderate AR, or could represent a specific phenotype of cardiomyopathy (CMP) with concomitant AR. The aim of this study was to analyse progression of left ventricular (LV) impairment in moderate AR.Methods: All patients in our echocardiography database between 2005 and 2016 were screened to identify pure chronic moderate AR, excluding significant coronary artery disease (CAD) or concomitant valve disease. Remaining 152 patients were divided into three groups: (a) preserved systolic LV function; (b) reduced LV EF and prediagnosed concomitant cardiomyopathy (CMP); (c) reduced LV EF without prediagnosed CMP.Results: The majority patients (group A = 66%) had preserved systolic LV function, remaining oligosymptomatic with stable LVEDD at follow-up. Non-CMP patients with reduced EF at baseline (group C = 18%) were significantly older (group C: 74 vs. group A: 61 years, p < .001) whereas left ventricular end-diastolic diameter (LVEDD) significantly increased over time (p = .046). Development of renal insufficiency, atrial fibrillation and NYHA > II were significant risk factors linked to the worsening of LV function in patients with moderate AR.Conclusion: Preserved LV EF and LVEDD remain stable over a long lasting period in the majority of patients. However, these data suggest that some patients develop reduced LV EF, even without progression of AR to severe, especially if renal insufficiency or atrial fibrillation are present.

Clinical Impact of Chronic Aortic Regurgitation in Asymptomatic Patients with Native Aortic Valve Stenosis

ABSTRACT Background: The pathologic processes of aortic regurgitation (AR) and aortic stenosis (AS) can affect the rate of progression to symptoms differently, and insight into the management of mixed aortic disease is needed. We examined the impact of concomitant AR in asymptomatic patients with AS. Methods: We examined 308 asymptomatic patients (mean age, 76 ± 13 yrs; 62% men) with moderate or severe AS seen at our institution, and compared outcomes according to the presence of AR. Results: Over 5.5 [2.7, 6.7] years, the presence of AR significantly impacted outcomes in patients with moderate, but not severe AS. For patients with moderate AS, the 4-year survival free of death, cardiac symptoms, or aortic valve replacement (AVR) was 47.1%, 30.9%, and 29.0% for none, mild, and moderate/severe AR, respectively (p = 0.02), and this relation remained significant after adjustment for morbidities in multivariate analyses (HR, 2.21 [1.31–3.74] for moderate/severe AR, p = 0.003). The median time to symptom onset was shorter with worse AR in patients with moderate AS (34.8, 32.1, and 24.0 months for none, mild, and moderate/severe AR, respectively; p = 0.08). There was no relation of concomitant AR to increased risk of death, symptoms, and AVR in patients with severe AS. Conclusion: The presence of AR increases the risk of need for AVR, but not death, in patients with moderate AS. Asymptomatic patients with severe AS have comparable long-term outcomes regardless of AR severity. These data have implications for clinical follow up and timing of surgery.

TCT-686 Mixed aortic valve disease: Impact on outcome after transcatheter aortic valve implantation

The introduction of transcatheter valve implantation (TAVI) into clinical practice has provided new treatment options for patients with severe aortic valve stenosis. Mixed aortic valve disease with concomitant aortic regurgitation is common amongst these patients. We sought to investigate in