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Do Guideline-Based Indications Result in an Outcome Penalty for Patients With Severe Aortic Regurgitation?
Christophe de Meester1, Bernhard L Gerber1, David Vancraeynest1
1Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and the Divisions of Cardiology and Cardiothoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
Insights
Guideline triggers for aortic regurgitation surgery may indicate poorer outcomes. Operating before triggers, especially Class I, improves long-term survival and cardiovascular health.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Aortic Valve Disease Management
Background:
- Current guidelines for severe aortic regurgitation (AR) surgery triggers are based on 1980s data.
- These guideline triggers are associated with worse postoperative outcomes.
- Surgical techniques have advanced, potentially reducing AR surgery risks.
Purpose of the Study:
- To evaluate if surgical improvements have mitigated the negative impact of guideline triggers on postoperative outcomes in severe AR.
- To compare long-term survival and cardiovascular outcomes based on guideline trigger status at the time of surgery.
Main Methods:
- A cohort of 356 patients undergoing surgical correction for severe AR was analyzed.
- Patients were categorized by guideline trigger status (Class I, IIa, IIb, or none).
- Cox regression and Kaplan-Meier analyses, with inverse probability weighting, compared outcomes.
Main Results:
- Ten-year survival was significantly better for patients without triggers (89%) or with Class II triggers (85%) compared to Class I triggers (71%).
- Similar trends were observed for cardiovascular survival and heart failure hospitalizations.
- Mortality risk increased when left ventricular ejection fraction fell below 55% or end-systolic dimensions exceeded 20-22 mm/m².
Conclusions:
- Guideline-based Class I triggers for AR surgery are linked to substantial long-term risks.
- Patients with severe AR may benefit from earlier surgery, before guideline triggers manifest.
- Optimal surgical timing involves maintaining left ventricular ejection fraction >55% and end-systolic dimensions <20-22 mm/m².
Objectives:
The present study examines whether improvements have reduced the negative impact of guideline triggers on postoperative outcomes.
Background:
European and American guidelines for the management of severe aortic regurgitation (AR) define the triggers for AR surgery. These triggers are based on the results of studies performed in the 1990s analyzing outcomes of patients who underwent AR surgery in the 1980s. Although these triggers are used to indicate surgery, they have all been associated with poorer postoperative outcomes. In the meantime, innovations in operative techniques, including aortic valve repair, have allowed reducing the risk of surgery.
Methods:
A total of 356 consecutive patients undergoing surgical correction of severe AR were included in this study. Among them, 204 were operated on for a Class I, 17 for a Class IIa, 49 for a Class IIb, and 86 without any guideline triggers. Cox proportional hazards regression models and Kaplan-Meier survival curves were used to compare postoperative outcomes in the different groups. Inverse probability weighing was used to adjust for mismatched baseline characteristics.
Results:
Adjusted 10-year survival was better among patients without operative triggers (89 ± 4%) or with Class II triggers (85 ± 6%) than in patients with Class I triggers (71 ± 4%, p = 0.010). Similar results were obtained for cardiovascular survival and hospitalizations for heart failure. Spline function analyses indicated that mortality started to increase for left ventricular (LV) ejection fraction <55% and LV end-systolic dimensions >20 to 22 mm/m2. LV end-diastolic dimensions did not influence outcomes.
Conclusions:
Guideline-based Class I triggers for AR surgery carry major risks for long-term outcomes. This suggests that patients with severe AR should be operated on before the onset of these triggers; that is, at an asymptomatic stage, before LV ejection fraction falls below 55% or LV end-systolic dimensions exceeds 20 to 22 mm/m2.
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