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J Thorac Cardiovasc Surg 2008;136:1549-1557
© 2008 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Congestive heart failure complicating aortic regurgitation with medical and surgical management: A prospective study of traditional and quantitative echocardiographic markers

Delphine Detaint, MDa, Joseph Maalouf, MDa, Christophe Tribouilloy, MDa, Douglas W. Mahoney, MSb, Hartzell V. Schaff, MDc, A. Jamil Tajik, MDa, Maurice Enriquez-Sarano, MDa,*

a Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn
b Section of Biostatistics, Mayo Clinic, Rochester, Minn
c Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn

Received for publication March 21, 2008; revisions received June 10, 2008; accepted for publication July 22, 2008.

* Address for reprints: Maurice Enriquez-Sarano, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. (Email: Sarano.maurice{at}mayo.edu).

Objective: Congestive heart failure complicating aortic regurgitation is poorly described, and predictive roles of quantitative versus traditional (symptoms or low ejection fraction) surgical markers are unclear.

Methods: We prospectively enrolled 287 patients with aortic regurgitation (age, 61 ± 17 years; 68% male) in whom we performed quantitative Doppler echocardiographic analysis and personal physicians conducted management.

Results: After diagnosis, 40 congestive heart failure episodes occurred under medical management (10-year, 23% ± 4%) causing high subsequent mortality (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.2–6.8; P = .02). Patients with traditional surgical markers (symptoms or ejection fraction <50%) were surprisingly followed 1.4 ± 3.3 years under medical management with frequent congestive heart failure (adjusted risk, 4.9; 95% CI, 2.1–11.0; P < .001) and excess postoperative mortality (HR, 3.0; 95% CI, 1.3–7.1; P = .01). Quantitative American Society of Echocardiography aortic regurgitation grading and left ventricular end-systolic volume index independently predicted congestive heart failure (quantitative American Society of Echocardiography severe aortic regurgitation: HR, 3.6; 95% CI, 1.3–13.0; P = .015; end-systolic volume index ≥45 mL/m2: HR, 2.1; 95% CI, 1.03–4.4; P = .04) or death–congestive heart failure with incremental predictive value (P < .001). Higher congestive heart failure rates occurred with quantitative American Society of Echocardiography severe aortic regurgitation (regurgitant volume of ≥60 mL/beat or orifice of ≥30 mm2) versus quantitative American Society of Echocardiography mild aortic regurgitation (10-year: 44% ± 10% vs 15% ± 7%, P < .001) and end-systolic volume index of 45 mL/m2 or greater versus less than 45 mL/m2 (33% ± 7% vs 9% ± 2%, P < .001). Traditional markers (symptoms and ejection fraction <50%) had lower sensitivity for congestive heart failure than quantitative echocardiography (all P < .001). Cardiac surgery for aortic regurgitation markedly reduced congestive heart failure in quantitative American Society of Echocardiography severe aortic regurgitation (HR, 0.23; 95% CI, 0.08–0.68; P = .008) without excess mortality (P = .10).

Conclusion: This prospective study of aortic regurgitation shows frequent congestive heart failure under conservative management. Traditional surgical markers (symptoms and ejection fraction <50%) predict subsequent congestive heart failure but are insensitive, and rescue operations are often delayed and associated with excess mortality. Quantitative echocardiography provides congestive heart failure predictors that are independent, incremental, and more sensitive than traditional markers. Cardiac surgery for aortic regurgitation markedly reduces congestive heart failure rates in high-risk patients with aortic regurgitation.

Abbreviations and Acronyms AR = aortic regurgitation; CHF = congestive heart failure; CI = confidence interval; EF = ejection fraction; ERO = effective regurgitant orifice; ESVI = end-systolic volume index; HR = hazard ratio; LV = left ventricular; QASE = quantitative American Society of Echocardiography; RVol = regurgitant volume






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