Impact of early versus class I-triggered surgery on postoperative survival in severe aortic regurgitation: An observational study from the Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry

Vincent Hanet; Hans-Joachim Schäfers; Emmanuel Lansac; Laurent de Kerchove; Ismail El Hamansy; Jan Vojácek; Monica Contino; Anne-Catherine Pouleur; Christophe Beauloye; Agnès Pasquet; Jean-Louis Vanoverschelde; David Vancraeynest; Bernhard L Gerber

doi:10.1016/j.jtcvs.2023.06.018

Impact of early versus class I-triggered surgery on postoperative survival in severe aortic regurgitation: An observational study from the Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry

J Thorac Cardiovasc Surg. 2023 Jul 7:S0022-5223(23)00545-7. doi: 10.1016/j.jtcvs.2023.06.018. Online ahead of print.

Affiliations

¹ Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium.
² Surgery Department, Homburg-Saarland University Medical Center, Homburg, Germany.
³ Surgery Department, Institut Mutualiste Montsouris, Paris, France.
⁴ Surgery Department, Montréal Heart Institute, Montréal, Canada.
⁵ Surgery Department, Charles University Hospital, Hradec Kralove, Czech Republic.
⁶ Surgery Department, Socio Sanitaria Territoriale Università degli Studi di Milano, Milano, Italy.
⁷ Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium. Electronic address: Bernhard.gerber@uclouvain.be.

PMID: 37422134
DOI: 10.1016/j.jtcvs.2023.06.018

Abstract

Objectives: Class I triggers for severe and chronic aortic regurgitation surgery mainly rely on symptoms or systolic dysfunction, resulting in a negative outcome despite surgical correction. Therefore, US and European guidelines now advocate for earlier surgery. We sought to determine whether earlier surgery leads to improved postoperative survival.

Methods: We evaluated the postoperative survival of patients who underwent surgery for severe aortic regurgitation in the international multicenter registry for aortic valve surgery, Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry, over a median follow-up of 37 months.

Results: Among 1899 patients (aged 49 ± 15 years, 85% were male), 83% and 84% had class I indication according to the American Heart Association and European Society of Cardiology, respectively, and most were offered repair surgery (92%). Twelve patients (0.6%) died after surgery, and 68 patients died within 10 years after the procedure. Heart failure symptoms (hazard ratio, 2.60 [1.20-5.66], P = .016) and either left ventricular end-systolic diameter greater than 50 mm or left ventricular end-systolic diameter index greater than 25 mm/m² (hazard ratio, 1.64 [1.05-2.55], P = .030) predicted survival independently over and above age, gender, and bicuspid phenotype. Therefore, patients who underwent surgery based on any class I trigger had worse adjusted survival. However, patients who underwent surgery while meeting early imaging triggers (left ventricular end-systolic diameter index 20-25 mm/m² or left ventricular ejection fraction 50% to 55%) had no significant outcome penalty.

Conclusions: In this international registry of severe aortic regurgitation, surgery when meeting class I triggers led to postoperative outcome penalty compared with earlier triggers (left ventricular end-systolic diameter index 20-25 mm/m² or ventricular ejection fraction 50%-55%). This observation, which applies to expert centers where aortic valve repair is feasible, should encourage the global use of repair techniques and the conduction of randomized trials.

Keywords: aortic regurgitation; guidelines; surgery; survival.