Valve Replacement In Asymptomatic Patients Research Articles

Rationale and design of the early valve replacement in severe asymptomatic aortic stenosis trial

Aortic valve replacement in asymptomatic severe aortic stenosis is controversial. The Early valve replacement in severe ASYmptomatic Aortic Stenosis (EASY-AS) trial aims to determine whether early aortic valve replacement improves clinical outcomes, quality of life and cost-effectiveness compared to a guideline recommended strategy of 'watchful waiting'. In a pragmatic international, open parallel group randomized controlled trial (NCT04204915), 2844 patients with severe aortic stenosis will be randomized 1:1 to either a strategy of early (surgical or transcatheter) aortic valve replacement or aortic valve replacement only if symptoms or impaired left ventricular function develop, or other cardiac surgery becomes nessessary. Exclusion criteria include other severe valvular disease, planned cardiac surgery, ejection fraction <50%, previous aortic valve replacement or life expectancy <2 years. The primary outcome is a composite of cardiovascular mortality or heart failure hospitalization. The primary analysis will be undertaken when 663 primary events have accrued, providing 90% power to detect a reduction in the primary endpoint from 27.7% to 21.6% (hazard ratio 0.75). Secondary endpoints include disability-free survival, days alive and out of hospital, major adverse cardiovascular events and quality of life. Recruitment commenced in March 2020 and is open in the UK, Australia, New Zealand, and Serbia. Feasibility requirements were met in July 2022, and the main phase opened in October 2022, with additional international centers in set-up. The EASY-AS trial will establish whether a strategy of early aortic valve replacement in asymptomatic patients with severe aortic stenosis reduces cardiovascular mortality or heart failure hospitalization and improves other important outcomes.

Evolving Concept of Aortic Valve Replacement in Asymptomatic Patients With Severe Aortic Stenosis

BackgroundSurgical treatment of asymptomatic severe aortic stenosis (AS) has been gaining attention ever since the results of the Early Surgery Versus Conventional Treatment in Very Severe Aortic Stenosis (RECOVERY) and Aortic Valve replacement versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR) trials showed survival benefits with early surgical aortic valve replacement (SAVR). This study analyzed the long-term clinical and echocardiographic outcomes of SAVR in asymptomatic severe AS. MethodsBetween 2002 and 2020, 272 patients with asymptomatic severe AS and a left ventricular ejection fraction ≥50% underwent SAVR with or without concomitant aortic surgery and met the study criteria. The median follow-up was 8.5 years (interquartile range, 6-12.8 years), for a total of 2584 patient-years. The time course of the left ventricular mass index (LVMI) and the average E/E′ (ratio of the Doppler-derived E wave to the tissue Doppler-derived E′ wave) were assessed using 594 postoperative echocardiograms. The association of preoperative LVMI and average E/E′ with survival was assessed using Cox proportional hazards. ResultsThere was no operative mortality. On longitudinal analyses, LVMI improved in patients who presented with moderate or severe preoperative left ventricular hypertrophy (LVH). However, after the early decline in average E/E′, there was a late increase to greater than upper limit normal, particularly in patients with a preoperative average E/E′≥14. Postoperative survival was 100%, 94%, 84%, and 76% at 1, 5, 10, and 15 years, respectively, comparable to age- and sex-matched expected survival on the basis of the US general population. On adjusted Cox survival analysis, only moderate to severe LVH was associated with a survival penalty (hazard ratio], 2.32; 95% CI, 1.02-5.27; P = .045). ConclusionsIn asymptomatic patients with AS, SAVR restores survival and improves LVH, but patients with diastolic dysfunction are left with persistent dysfunction. Presentation with moderate or severe LVH at the time of surgery translated to a survival penalty. This observational study supports early SAVR in this population before development of LVH, although further investigation is needed.

Aortic Stenosis: Risk Stratification and Timing of Surgery.

This review summarizes the current management of patients with newly diagnosed aortic stenosis. Recent developments include detection of early myocardial dysfunction using serum B-type natriuretic peptide levels and global longitudinal strain, as well as ongoing trials of transcatheter aortic valve replacement in asymptomatic patients and patients with moderate aortic stenosis complicated by symptoms or left ventricular systolic dysfunction. Given the high mortality associated with severe symptomatic aortic stenosis, all symptomatic patients should be referred for aortic valve replacement. Asymptomatic patients with left ventricular systolic dysfunction, abnormal exercise stress test, high degree of stenosis, rapid disease progression, or elevated serum B-type natriuretic peptide level may also have an indication for valve replacement, based on established criteria. The progress in management of severe aortic stenosis has been in the direction of earlier detection and earlier valve replacement.

Machine Learning Prediction Models of Optimal Time for Aortic Valve Replacement in Asymptomatic Patients

Currently, the decision of aortic valve replacement surgery time for asymptomatic patients with moderate-to-severe aortic stenosis (AS) is made by healthcare professionals based on the patient’s clinical biometric records. A delay in surgical aortic valve replacement (SAVR) can potentially affect patients’ quality of life. By using ML algorithms, this study aims to predict the optimal SAVR timing and determine the enhancement in moderate-to-severe AS patient survival following surgery. This study represents a novel approach that has the potential to improve decision-making and, ultimately, improve patient outcomes. We analyze data from 176 patients with moderate-to-severe aortic stenosis who had undergone or were indicated for SAVR. We divide the data into two groups: those who died within the first year after SAVR and those who survived for more than one year or were still alive at the last follow-up. We then use six different ML algorithms, Support Vector Machine (SVM), Classification and Regression Tree (C and R tree), Generalized Linear (GL), Chi-Square Automatic Interaction Detector (CHAID), Artificial Neural Network (ANN), and Linear Regression (LR), to generate predictions for the best timing for SAVR. The results showed that the SVM algorithm is the best model for predicting the optimal timing for SAVR and for predicting the post-surgery survival period. By optimizing the timing of SAVR surgery using the SVM algorithm, we observed a significant improvement in the survival period after SAVR. Our study demonstrates that ML algorithms generate reliable models for predicting the optimal timing of SAVR in asymptomatic patients with moderate-to-severe AS.

Early surgical aortic valve replacement in asymptomatic patients with severe aortic stenosis: a systematic review and meta-analysis.

Early surgical aortic valve replacement in asymptomatic patients with severe aortic stenosis: a systematic review and meta-analysis.

Factors associated with the need for pulmonary valve replacement in asymptomatic patients with isolated pulmonary regurgitation after repair of tetralogy of Fallot: a cardiac magnetic resonance study.

Pulmonary regurgitation (PR) is the most common late complication in patients after repair of tetralogy of Fallot (TOF). Most patients remain asymptomatic over years, but eventually, the compensatory mechanisms fail, leading to right ventricular (RV) dilation and dysfunction, limited exercise capacity, ventricular arrhythmia, and sudden death. We aimed to evaluate associations between cardiac magnetic resonance (CMR) parameters and the need for either surgical or percutaneous pulmonary valve replacement (PVR) in asymptomatic patients with significant PR after repair of TOF. Of 209 patients with repaired TOF who had undergone a CMR study, we selected 61 asymptomatic patients with moderate‑to‑severe PR and followed them for up to 4 years (mean [SD], 21.4 [13.7] months). We excluded patients with residual ventricular septal defect, a peak RV outflow tract gradient of 30 mm Hg or higher, or at least moderate tricuspid regurgitation. Receiver operating characteristic curve analyses revealed that the ratio of RV to left ventricular (LV) volume (RV/ LV ratio; threshold >2.4) and PR fraction (PRF; threshold >33%) had acceptable discriminatory capacity to differentiate between patients requiring PVR and those treated conservatively. The Cox proportional hazards regression and the Kaplan–Meier curves revealed that the RV / LV ratio and PRF was significantly associated with the need for PVR. The combination of the RV / LV ratio and PRF provided significant discrimination in terms of survival without PVR (P <0.001; log‑rank test for trend). The RV/ LV ratio and PRF were significantly associated with the need for PVR in asymptomatic patients with isolated moderate‑to‑severe PR after repair of TOF.

Right ventricular systolic dysfunction but not dilatation correlates with prognostically significant reductions in exercise capacity in repaired Tetralogy of Fallot.

The optimal timing for pulmonary valve replacement in asymptomatic patients with repaired Tetralogy of Fallot (rTOF) and pulmonary regurgitation remains uncertain but is often guided by increases in right ventricular (RV) end-diastolic volume. As cardiopulmonary exercise testing (CPET) performance is a strong prognostic indicator, we assessed which cardiovascular magnetic resonance (CMR) parameters correlate with reductions in exercise capacity to potentially improve identification of high-risk patients. In all, 163 patients with rTOF (mean age 24.5 ± 10.2 years) who had previously undergone CMR and standardized CPET protocols were included. The indexed right and left ventricular end-diastolic volumes (RVEDVi, LVEDVi), right and left ventricular ejection fractions (RVEF, LVEF), indexed RV stroke volume (RVSVi), and pulmonary regurgitant fraction (PRF) were quantified by CMR and correlated with CPET-determined peak oxygen consumption (VO2) or peak work. On univariable analysis, there was no significant correlation between RVEDVi and PRF with peak VO2 or peak work (% Jones-predicted). In contrast, RVEF and RVSVi had significant correlations with both peak VO2 and peak work that remained significant on multivariable analysis. For a previously established prognostic peak VO2 threshold of <27 mL/kg/min, receiver-operating characteristic curve analysis demonstrated a Harrell's c of 0.70 for RVEF (95% confidence interval 0.61-0.79) with a sensitivity of 88% for RVEF <40%. In rTOF, CMR indices of RV systolic function are better predictors of CPET performance than RV size. An RVEF <40% may be useful to identify prognostically significant reductions in exercise capacity in patients with varying degrees of RV dilatation.

Rationale and design of the randomized, controlled Early Valve Replacement Guided by Biomarkers of Left Ventricular Decompensation in Asymptomatic Patients with Severe Aortic Stenosis (EVOLVED) trial

The optimal timing of aortic valve replacement in asymptomatic patients with aortic stenosis is uncertain. Replacement fibrosis, as assessed by midwall (nonischemic) late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging, is an irreversible marker of left ventricular decompensation in aortic stenosis. Once established, it progresses rapidly and is associated with poor long-term prognosis in a dose-dependent manner. The objective of this multicenter prospective randomized controlled trial is to determine whether early aortic valve replacement in asymptomatic patients with severe aortic stenosis can improve the adverse prognosis associated with midwall LGE. Patients will be screened for likelihood of having LGE with electrocardiography or high-sensitivity troponin I. Those at high risk will proceed to CMR imaging. Approximately 400 patients with midwall LGE will be randomized 1:1 to early valve replacement or routine care. Those who do not exhibit midwall LGE will continue with routine care and be randomized to a study registry or no further follow-up. Follow-up will be annual for approximately 3 years until the number of required outcome events is achieved. The primary endpoint is a composite of all-cause mortality and unplanned aortic stenosis-related hospitalization. The expected event rate is 25.0% in the routine care arm and 13.4% in the early intervention arm over the first 2 years; 88 observed primary outcome events will give 90% power at 5% significance level. Key secondary endpoints include all-cause mortality, sudden cardiac death, stroke, and symptomatic status. The EVOLVED trial is the first multicenter randomized controlled trial to compare early aortic valve replacement to routine care in asymptomatic patients with severe aortic stenosis and midwall LGE.

Thresholds for Valve Replacement in Asymptomatic Patients With Aortic Stenosis

Thresholds for Valve Replacement in Asymptomatic Patients With Aortic Stenosis

Optimal timing for pulmonary valve replacement in asymptomatic patients after tetralogy of Fallot repair using cardiac magnetic resonance imaging.

Optimal timing for pulmonary valve replacement in asymptomatic patients after tetralogy of Fallot repair using cardiac magnetic resonance imaging.

Basal longitudinal strain predicts future aortic valve replacement in asymptomatic patients with aortic stenosis.

To evaluate the prognostic value of global longitudinal strain (GLS) and basal longitudinal strain (BLS) with the knowledge of coexisting coronary pathology evaluated by multi-detector computed tomography (MDCT) coronary angiography. GLS and BLS are both sensitive markers of myocardial dysfunction and predictors of outcome in asymptomatic aortic stenosis. Aortic stenosis and ischaemic heart disease share risk factors and longitudinal function can be severely reduced in both conditions, why some of the previous findings of impaired regional longitudinal function in asymptomatic aortic stenosis could in fact be explained by silent ischaemic heart disease. Prospective follow-up of 104 asymptomatic patients with moderate-severe aortic stenosis defined as an aortic valve area <1.5 cm(2). Patients underwent a thorough clinical work-up, advanced echocardiographic analysis and coronary angiography by MDCT. The combined endpoint was indication for aortic valve replacement (AVR) and sudden cardiac death. During a median follow-up of 2.3 years (interquartile range 1.7-3.6) 43 patients (41%) met the endpoint of indication for AVR. The basal (13.4 ± 3.1% vs. 15.7 ± 3.1%) and mid-ventricular segments (14.9 ± 2.7% vs. 16.2 ± 2.9%) were significantly reduced, but with sparing of the apical segments, in patients who later underwent AVR. In various multivariable Cox regression models, including only BLS, but not GLS, remained an independent predictor of AVR. In contrast to GLS, reduced BLS is a significant predictor of future AVR in asymptomatic patients with aortic stenosis, independently of clinical characteristics, conventional echocardiographic measures, and coronary pathology.

Percutaneous Pulmonary Valve Implantation

In this issue of Circulation: Cardiovascular Interventions , Borik et al1 review the intermediate and long-term echocardiographic, MRI and cardiopulmonary exercise results in a cohort of 51 patients followed for a mean of 4.5±1.9 (0.9–6.9) years after percutaneous pulmonary valve implantation (PPVI). The majority of patients had mixed pulmonary stenosis (PS) and pulmonary regurgitation (PR; 32/51) or predominant PS (16/51). The cohort is divided into patients 16 years. Clinical outcomes are favorable in the overall cohort, no differences were noted in the need for reintervention or reoperation between the younger and older groups and there was only one episode of endocarditis. Incremental improvements in right ventricular size by echo and MRI were noted in younger patients and there was a trend toward improvement in right ventricular ejection fraction in patients <16 years of age. Moreover, the authors noted greater improvement in maximum oxygen consumption in younger patients, those with lower preimplantation right-sided pressures, and those with better ventricular function and aerobic capacity before implantation. The improvements in aerobic capacity occurred within the first year and plateaued thereafter. The authors concluded that PPVI in younger patients with right ventricular outflow tract (RVOT) dysfunction is associated with improved aerobic exercise capacity and right ventricular dimensions. See Article by Borik et al There is general consensus among experts in congenital heart disease that symptomatic patients with RVOT dysfunction should undergo pulmonary valve replacement.2 Symptomatic patients include those with decreased functional capacity, evidence of heart failure, and arrhythmias. The timing of pulmonary valve replacement in asymptomatic patients with RVOT dysfunction is more controversial. Coats et al3 demonstrated that patients with RVOT obstruction, defined as an echo Doppler-derived peak systolic gradient ≥50 mm Hg, benefited from PPVI with resultant immediate reductions …

Concurrent Carotid Endarterectomy and Coronary Artery Bypass Grafting / Valve Replacement in Asymptomatic Patients with Severe Carotid Stenosis: A Five Year Single Center Experience

Concurrent Carotid Endarterectomy and Coronary Artery Bypass Grafting / Valve Replacement in Asymptomatic Patients with Severe Carotid Stenosis: A Five Year Single Center Experience

Prognostic value of low-dose dobutamine testing in asymptomatic patients with moderate or severe aortic stenosis and preserved ejection fraction

Purpose: In Aortic Stenosis (AS) most Doppler-echocardiographic indices that are used for assessing AS severity are flow dependent. The aim of this study was to assess prognostic value of low-dose Dobutamine Testing (DT) in patients with moderate or severe AS and preserved Ejection Fraction (EF). Method: A total of 126 asymptomatic patients with aortic valve area (AVA) ≤1.5 cm2 and EF >50% were enrolled in this prospective study. The follow-up period was 14±2 months. Mean age was 66.47±10.53; (58.73% males), mean EF was 72,03±6,69%, mean pressure gradient (Pmean) 41.94±11.22 mmHg and mean AVA 0.82±0.22 cm2. Patients with ≥2+ valvular regurgitation or more than mild mitral stenosis were excluded. The dobutamine infusion protocol was begun at 5 μg/kg/min body weight up to 20 μg/kg/min, titrated upwards at steps of 5 μg/kg/min every 3 min. The composite outcome endpoint (MACE) was defined as cardiac death, aortic valve replacement and hospitalization caused by AS symptoms according to patient's medical record. Results: No patient experienced a serious adverse event during or after DT. A total of 70 patients had MACE (55.55%), of which 9 patients (7.14%) have died during follow-up. Out of 70 patients, 56 patients (80%) had an Aortic Valve Replacement (RAV). Patients who had an increase in AVA during DT ≤0.2 cm2 and/or final AVA ≤1 cm2 had more often RAV (hi=9.5311; df=1; p=0.002). The lasso penalized Cox regression, conducted solely on the variables at rest, showed that the greatest predictive capacity has the aortic valve resistance (AVR). At the same time, the AUC for the all analyzed pre-dobutamine variables combined, evaluated at time = 12 months, was 0.76. On the other hand, the L1 procedure, when applied on all variables (pre and during DT), chooses only dobutamine variables as the most valuable in predictive sense, improving AUC by 6% (AUC =0.82, at time = 12 months). The value of the AVR obtained during the DT was the strongest independent one-year MACE predictor (according to bootstrapped p values) of all pre and during DT varaibles, with the value of 195.12 dynes s cm-5 having the highest sensitivity ans specificity in predicting MACE (0.78 and 0.73 respectively). In addition, patients who have experienced symptoms (11/126, 8.73%) during DT had more often MACE comparing to asymptomatic patients (hi=6,7408; p<0,001; df=1). Conclusion: The present study demonstrates that AVR, as well as flow-mediated changes during DT, can provide new, clinically relevant information in terms of outcome and timing of valve replacement in asymptomatic patients with moderate and severe AS and preserved EF.

Meta-Analysis of Prognostic Value of Stress Testing in Patients With Asymptomatic Severe Aortic Stenosis

The management strategy in asymptomatic patients with severe aortic stenosis (AS) is controversial. Aortic valve replacement has significant morbidity and mortality, while there is a risk for sudden cardiac death with conservative management. There is no consensus on the prognostic value of stress testing to stratify management. A pooled analysis of studies in patients with severe AS was performed to assess the prognostic value of stress testing for adverse events, including angina, dyspnea, acute heart failure, sudden death, and symptoms requiring aortic valve replacement. A search of published research was performed using the terms "stress test" and "asymptomatic aortic stenosis." A random-effects model was used to calculate pooled odds ratios and 95% confidence intervals. Data from 7 studies were included (491 patients with asymptomatic severe AS). None of the patients experienced any complications during or after stress testing. There were no sudden deaths in the patients with normal stress test results after 1 year of follow-up, while 5% with abnormal stress test results had sudden cardiac death. Overall, 52 of 253 patients (21%) with normal stress test results had adverse cardiac events, compared with 156 of 238 (66%) with abnormal stress test results (odds ratio 0.12, 95% confidence interval 0.07 to 0.21, p <0.001). In conclusion, stress testing in asymptomatic patients with severe AS is safe and identifies patients at risk for adverse cardiac events and sudden cardiac death. These data suggest that stress tests can be used for risk stratification and for deciding on the timing of aortic valve replacement in asymptomatic patients with severe AS.

Consequences of a selective approach toward pulmonary valve replacement in adult patients with tetralogy of Fallot and pulmonary regurgitation

The aim of the study was to assess the long-term results of a selective policy toward pulmonary valve replacement in adult patients with repaired tetralogy of Fallot and severe pulmonary regurgitation. Sixty-seven patients with tetralogy of Fallot were followed up from 15 +/- 3 years until 27 +/- 3 years after surgery. Twenty-two patients had mild-to-moderate pulmonary regurgitation. No significant changes occurred in the follow-up period. Of 45 patients with severe pulmonary regurgitation and severe right ventricular dilatation, 28 (62%) remained free of symptoms and did not undergo pulmonary valve replacement. No changes in right ventricular size or exercise capacity were found. In 3 (11%) of 28 patients, QRS duration increased to more than 180 ms. Seventeen patients had symptoms and underwent pulmonary valve replacement: 9 (54%) of 17 patients improved clinically and echocardiographically, and QRS duration shortened postoperatively. Right ventricular dimensions did not regress despite pulmonary valve replacement in 8 patients. Refraining from pulmonary valve replacement in asymptomatic patients led to no measurable deterioration in 25 (89%) of 28 patients. Referring symptomatic patients for pulmonary valve replacement led to an improvement in 9 (53%) of 17 patients. In 11 (24%) of 45, a selective approach led to questionable or unsatisfactory results.

The benefits of early valve replacement in asymptomatic patients with severe aortic stenosis

The prevalence of aortic valve stenosis increases with age, and often the diagnosis is made by echocardiography before symptoms develop. To address the controversies in management of asymptomatic patients with severe aortic stenosis, we assessed the early and late outcomes of aortic valve replacement in these patients. We analyzed data of 622 patients, aged 72 +/- 11 years, with isolated asymptomatic severe aortic stenosis. Patients were identified with a peak systolic velocity of greater than 4 m/s by transthoracic echocardiography and monitored for the development of symptoms and need for aortic valve replacement. After the initial diagnosis, 166 (27%) patients who were initially asymptomatic experienced the development of chest pain, shortness of breath, or syncope and had aortic valve replacement at Mayo Clinic. Another 97 (16%) patients had aortic valve replacement in the absence of symptoms. Symptomatic patients were more likely to undergo coronary bypass grafting (P < .01) and have diabetes, hypercholesterolemia, and a lower ejection fraction (P < .05 for each). Operative mortality was 2% for symptomatic patients and 1% for asymptomatic patients (P = .43). The survival of the 263 patients who underwent aortic valve replacement was not significantly different from an age- and sex-matched population (P = .99); 10-year survival was 64% (95% confidence interval [CI] 57%-72%) for symptomatic patients and 64% (95% CI 54%-75%) for asymptomatic patients (P = .92). At 3 years after diagnosis of severe aortic stenosis, 52% (95% CI 48%-56%) of 622 patients had had symptoms develop, undergone aortic valve replacement, or died. Among the entire cohort, older age at diagnosis (hazard ratio [HR] 1.1 per year, P < .001), diabetes (HR 1.7, P < .001), decreased ejection fraction (HR 1.1 per 1% downward arrow, P = .01), symptoms (HR 2.13, P < .001), and absence of aortic valve replacement (HR 3.53, P < .001) were identified as independent risk factors for mortality. Among patients with severe aortic stenosis who underwent aortic valve replacement, early and late outcomes were similarly good in patients who had symptoms before the operation compared with those who were asymptomatic. It is important to note that among patients with asymptomatic severe aortic stenosis, the omission of surgical treatment was the most important risk factor for late mortality.

Long-term Survival and Functional Results After Aortic Valve Replacement in Asymptomatic Patients With Chronic Severe Aortic Regurgitation and Left Ventricular Dysfunction

Long-term Survival and Functional Results After Aortic Valve Replacement in Asymptomatic Patients With Chronic Severe Aortic Regurgitation and Left Ventricular Dysfunction

Long-Term Survival and Functional Results After Aortic Valve Replacement in Asymptomatic Patients With Chronic Severe Aortic Regurgitation and Left Ventricular Dysfunction

Long-Term Survival and Functional Results After Aortic Valve Replacement in Asymptomatic Patients With Chronic Severe Aortic Regurgitation and Left Ventricular Dysfunction

Long-term survival and functional results after aortic valve replacement in asymptomatic patients with chronic severe aortic regurgitation and left ventricular dysfunction

We examined the influence of medical treatment on the results of surgery in terms of long-term survival and functional results in patients with chronic, severe aortic regurgitation (AR). Asymptomatic patients with AR and a reduced left ventricular ejection fraction (LVEF) are at high risk because of a higher-than-expected long-term mortality. The influence of preoperative medical therapy on the outcome after aortic valve replacement (AVR) is not well known. Surgery was indicated for the appearance of a reduced LVEF (<50%). At the time of AVR, there were 134 patients treated with nifedipine (group A), and 132 received no medication (group B). Operative mortality was similar in the two groups (0.75% vs. 0.76%, p = NS). The LVEF normalized in all of group A, whereas it remained abnormal in 36 group B patients (28%). At 10-year follow-up, LVEF persisted higher in group A (62 +/- 5% vs. 48 +/- 4%, p < 0.001). Five-year survival was similar in the two groups (94 +/- 2% vs. 94 +/- 3%, p = NS). Group A showed a 10-year survival not different from expected and significantly higher than that in group B (85 +/- 4% vs. 78 +/- 5%, p < 0.001), which had a worse survival than expected. Unloading treatment with nifedipine in AR allows one to indicate AVR at the appearance of a reduced LVEF with a low operative mortality and an optimal long-term outcome. The concept of surgical correction of AR indicated for reduced LVEF may not be applied to all patients. Indeed, in a large amount of untreated patients, a reduced LVEF preoperatively is not reversed by prompt surgery, indicating irreversible myocardial damage, and 10-year survival is worse than expected.