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Ann Thorac Surg 2009;87:1170-1176. doi:10.1016/j.athoracsur.2008.12.086
© 2009 The Society of Thoracic Surgeons
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Morgan L. Brown
Hartzell V. Schaff
Rakesh M. Suri
Thoralf M. Sundt
Joseph A. Dearani
Richard C. Daly
Thomas A. Orszulak
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Original Articles: Adult Cardiac

Indexed Left Ventricular Dimensions Best Predict Survival After Aortic Valve Replacement in Patients With Aortic Valve Regurgitation

Morgan L. Brown, MDa, Hartzell V. Schaff, MDa,*, Rakesh M. Suri, MDa, Li Zhuo, MSb, Thoralf M. Sundt, MDa, Joseph A. Dearani, MDa, Richard C. Daly, MDa, Thomas A. Orszulak, MDa

a Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
b Division of Biostatistics, Mayo Clinic, Rochester, Minnesota

Accepted for publication December 26, 2008.

* Address correspondence to Dr Schaff, Mayo Clinic, 200 1st St SW, Rochester MN 55905 (Email: schaff{at}mayo.edu).

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comments
 Discussion
 References
 
Background: Indications for valve replacement in patients with aortic regurgitation include diminished ejection fraction and increased left ventricular dimensions. Our objective was to examine the effect of preoperative ejection fraction and left ventricular dimensions on survival and return of normal systolic function (ejection fraction ≥ 0.50) after valve replacement for aortic regurgitation.

Methods: Between 1996 and 2006, 301 patients had aortic valve replacement for moderate or greater chronic aortic regurgitation, and 29% had concomitant replacement of the ascending aorta. We reviewed clinical and echocardiographic variables as well as late vital status.

Results: Patients' mean age was 55.2 ± 16.5 years, and 78% were male. The mean preoperative ejection fraction was 0.56 ± 0.12, the mean left ventricular end-systolic dimension was 43 ± 10 mm, and the mean left ventricular end-diastolic dimension was 63 ± 9 mm. Operative mortality was 1.7%, and survival at 1, 5, and 10 years was 96%, 90%, and 77%, respectively. This was similar to an age- and sex-matched population (p = 0.214). The level of ejection fraction preoperatively did not predict late survival, nor did absolute values for left ventricular end-systolic dimension and end-diastolic dimension. Indexed left ventricular end-systolic dimension and end-diastolic dimension were predictors (p < 0.01) of late survival. Data from late echocardiography were available for 159 patients (56%) at a mean follow-up of 3.3 ± 2.6 years. Preoperative ejection fraction, left ventricular end-systolic dimension, indexed end-systolic dimension, end-diastolic dimension, and indexed end-diastolic dimension were univariately predictive of late ejection fraction. In a multivariate model the only predictor of late normal ejection fraction was a higher preoperative ejection fraction (odds ratio, 2.85; p < 0.001).

Conclusions: In patients who received a valve replacement for aortic regurgitation, decreased ejection fraction and increased left ventricular dimensions were not associated with late mortality. However, larger indexed left ventricular systolic and diastolic dimensions were associated with late mortality. Preservation of late ejection fraction is best if the operation is performed in patients with near normal preoperative left ventricular function.


   Introduction
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 Abstract
 Introduction
Material and Methods
 Results
 Comments
 Discussion
 References
 
The American Heart Association and American College of Cardiology have published guidelines regarding the timing of operative intervention in patients with chronic aortic regurgitation (AR) [1]. In the absence of randomized trials, these guidelines are based on natural history studies, which demonstrate high mortality in patients who develop symptoms [2–11], and, thus, the presence of symptoms in patients with severe chronic AR is considered a class I indication for aortic valve replacement (AVR). To determine the timing of surgery, the guidelines also consider the outcomes of AVR including survival, symptomatic status, and late morbidity.

It is known, however, that significant left ventricular (LV) dysfunction may occur in the absence of symptoms in patients with chronic severe AR. Both low ejection fraction (EF) and large LV dimensions are associated with increased late mortality [12–31]. Thus, the American Heart Association/American College of Cardiology guidelines also reflect the importance of prompt AVR in asymptomatic patients if there is a decreased EF of 0.50 or less (class I indication). As a class IIa recommendation, the guidelines suggest that AVR is reasonable in asymptomatic patents with severe AR with a normal EF in the presence of an LV end-diastolic dimension (EDD) of greater than 75 mm and an end-systolic dimension (ESD) of greater than 55 mm. The guidelines also include a caveat to consider lower thresholds in patients of smaller stature.

Our objectives were to assess the echocardiographic predictors of survival and normal EF (≥0.50) at late follow-up in patients with severe chronic AR who had AVR. We also examined the early changes in LV function after AVR and its impact on these late outcomes.


   Material and Methods
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 Abstract
 Introduction
 Material and Methods
Results
 Comments
 Discussion
 References
 
After institutional review board approval, which waived the need to obtain specific patient consent, we reviewed adult patients (>18 years) who underwent AVR between January 1, 1996, and January 1, 2006. To select only those patients with chronic isolated AR of a moderate or greater severity, patients were excluded who had moderate or greater aortic stenosis on preoperative transthoracic echocardiography. As well, patients were excluded who had prior or concomitant coronary artery bypass grafting or mitral valve repair or replacement, complex congenital heart disease, or subaortic stenosis. Patients with acute AR, including aortic dissections or active endocarditis, were also excluded.

Follow-up was ascertained using both the medical chart and survey follow-up. Vital status was assessed through an online database (www.Accurint.com), the medical record, correspondence with health-care providers, and from the medical questionnaire. Echocardiograms were reviewed from our prospective echocardiographic follow-up database. Preoperative, predismissal, and follow-up transthoracic echocardiograms were reviewed. Echocardiograms were considered preoperative if they were performed less than 1 year before operation, predismissal if they were performed 48 hours or greater after operation and before dismissal from hospital, and follow-up if echocardiography was performed 14 days or greater after operation. Ejection fraction and ventricular dimensions were measured according to recommendations by the American Society of Echocardiographers [32]. All echocardiographic measurements were indexed to body surface area.

Statistical analyses were performed using SAS (version 9.1, SAS Institute, Cary, NC). Data are presented as mean and standard deviation or number and percentage, as appropriate. One-way analysis of variance tests were used to compare changes in EF among groups. Univariate and stepwise multivariate models were created using logistic regression for binary outcomes and Cox proportional hazards for time-related data. Kaplan–Meier curves were compared using a log-rank test. Cutoff points of LVEDD and LVESD in predicting late survival were explored using a previously created macro by the Mayo Clinic. The cutoff points recommended are based on the highest hazard ratios and the lowest probability values.


   Results
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 Abstract
 Introduction
 Material and Methods
 Results
Comments
 Discussion
 References
 
Our final cohort consisted of 301 patients whose demographic characteristics are described in Table 1. Almost 60% of patients had isolated AVR; 89 patients had concomitant repair of the ascending aorta (composite AVR in 16 and supracoronary graft in 73; Table 2). Ten percent of patients had undergone previous aortic valve repair. The operative mortality (<30 days) was 1.7% (5 patients). No risk factors could be identified for early mortality owing to the low number of events. Data from preoperative echocardiography were available in 283 patients, predismissal in 270 patients, and at follow-up in 169 patients. The median time of late follow-up echocardiography was 3.3 ± 2.6 years (interquartile range, 1.0 to 5.1). In 147 patients (49%), echocardiographic measurements of EF were available at all time intervals. Late survival status (>30 days) was available in 94% of patients at a mean duration of 4.4 ± 3.2 years.


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  		Table 1 Patient Characteristics
 

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  		Table 2 Operative Characteristics
 
The 5- and 10-year survival of patients undergoing AVR for chronic AR was 90% (95% confidence interval, 86 to 94) and 77% (95% confidence interval, 69 to 86), respectively. When this was compared with an age- and sex-matched Minnesotan population, patients who had an AVR for chronic AR had a statistically similar survival (p = 0.214; Fig 1). On univariate analysis, both larger LVEDD (indexed) and LVESD (indexed) were associated with greater late mortality, but LVEDD and LVESD (not adjusted for body surface area) were not significant predictors of mortality. Importantly, preoperative EF was of only borderline significance as a continuous variable and was not associated with late survival when dichotomized to normal (≥0.50) and abnormal (<0.50; p = 0.086). As well, survival was not influenced by the magnitude of a decrease in EF from preoperative to predismissal echocardiograms (Table 3).


Figure 1
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  		Fig 1. Survival after aortic valve replacement (AVR) for chronic aortic insufficiency (AR) compared with an age- and sex-matched population.

 

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  		Table 3 Preoperative Echocardiographic Univariate Predictors of Late Mortality After Aortic Valve Replacement for Aortic Regurgitation
 
We stratified patients into groups based on both indexed LVEDD and indexed LVESD (Fig 2). Late survival was significantly better in patients with a smaller indexed LVESD, with the best cutoff at 20 mm/m2 (p < 0.001). We also assessed the difference in survival at a cut point of indexed LVESD of 25 mm/m2 (p < 0.001). Survival was greater in patients who had an indexed LVEDD of less than 30 mm/m2. When patients with indexed LVEDD were divided into less than 35 mm/m2 and 35 mm/m2 or greater, survival was not statistically significantly different (p = 0.056).


Figure 2
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  		Fig 2. Survival after aortic valve replacement adjusted for age and stratified by left ventricular indexed end-systolic dimensions (LVESD; A) and indexed left ventricular end-diastolic dimensions (LVEDD; B).

 
Comparing preoperative and predismissal echocardiograms, LVEF was reduced from 0.56 ± 0.12 to 0.49 ± 0.15. When stratified by preoperative EF, patients with a higher preoperative EF appear to have the greatest reduction in EF at dismissal and the highest EF at follow-up (Fig 3). Univariate predictors of a decrease in EF before hospital dismissal included larger preoperative LVEDD and indexed LVEDD, and a higher preoperative EF. On multivariate analysis, a higher preoperative EF (slope = 3.3; p < 0.001) and a larger preoperative LVEDD (slope = 4.5; p < 0.001) were predictive of a greater early reduction in EF after AVR.


Figure 3
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  		Fig 3. Change in ejection fraction (EF) after operation stratified by preoperative ejection fraction. All patients had available echocardiography at all time points. The mean follow-up time was 3.3 ± 2.6 years. There was a greater initial reduction in ejection fraction in patients with the greatest preoperative ejection fraction (p = 0.014). However, those patients with the lowest preoperative ejection fraction had the greatest improvement of ejection fraction at late follow-up (p < 0.001).

 
At late follow-up, 80% of patients had an EF of 0.50 or greater on transthoracic echocardiography. Univariate predictors of late normal EF included a greater preoperative EF and a smaller LVESD or indexed LVESD. The initial change in LVEF from preoperative to predismissal was not predictive of late normal EF (Table 4). On multivariate analysis, only higher preoperative EF was predictive of late return of normal LV function (hazard ratio, 2.85; p < 0.01).


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  		Table 4 Echocardiographic Predictors of Late Normal Ejection Fraction of 0.50 or Greater
 

   Comments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comments
Discussion
 References
 
In our study, patients who had AVR for chronic AR had a low operative mortality (1.7%), which compares favorably with previous studies (risk 3% to 14%) [3, 28, 29, 33–37]. This may be attributable to improved operative techniques as well as operating earlier on patients before development of severe LV failure. As well, late survival in our cohort was similar to an age- and sex-matched population at 10 years of follow-up (77%). In a study of patients who received the Starr-Edwards AVR for AR between 1962 and 1971, the 10-year survival was approximately 50% [38]. These findings suggest that in the current era, timely operation in conjunction with modern prostheses may allow patients to expect a normal lifespan after undergoing AVR for AR.

Ventricular EDD and ESD were predictive of late mortality but only after indexing for body surface area. Our findings are supported by a previous study by Sambola and colleagues [34], who found that preoperative LVESD and indexed LVESD were independent predictors of mortality or heart failure in patients after AVR for chronic AR. These authors also found that the use of an indexed value improved the prediction of these outcomes in patients with a low body surface area.

In a prior study from our clinic, in patients who had severe AR and had conservative treatment, survival at 10 years was 81% for patients with an indexed LVESD of less than 25 mm/m2 versus 34% in patients who had an indexed LVESD of 25 mm/m2 or greater [36]. The current study includes only patients in the more recent era who have had AVR at the Mayo Clinic.

Another earlier study from our institution found that women, who had a lower average body surface area than men, had poorer outcomes after AVR for AR [28]. In this study, indexed LV dimensions were not found to predict mortality [28], but again, this was from an earlier era (1980 to 1989). The poor outcomes may be related also to the tendency of women to present with symptoms, as women rarely reach the unindexed LV dimension thresholds for AVR. In our study, sex was not a predictor of late survival. As well, we were unable to detect any difference in the ideal cutoff for LV dimensions among our group of women as our study was underpowered for this analysis. The current American Heart Association/American College of Cardiology guidelines acknowledge this, through a comment about accounting for patient body size. Our data support these recommendations and suggest that using indexed values for LV dimensions better predict late survival in patients with chronic AR.

Although clinicians agree that marked ventricular enlargement portends a poor prognosis for patients with aortic valve regurgitation, the degree of enlargement and, in particular, the cutoff for indexed LV dimensions is still debated [17, 36, 37, 39, 40]. The most commonly quoted indexed measurements are indexed LVESD less than 25 mm/m2 and indexed LVEDD of less than 35 mm/m2. In our study, separation of patients into groups with LVESD above or below 25 mm/m2 did demonstrate significant differences in overall survival, but the best discrimination in survival was seen at 20 mm/m2 for indexed LVESD and 30 mm/m2 for indexed LVEDD. The best cutoff should be further assessed in other surgical populations to determine a consensus.

Patients who have an increase in LVEF at 6 to 8 months after AVR for AR can be expected to have further improvement in ventricular function [41, 42]. However, late improvement is unlikely to occur in patients with no recovery in EF during the first 6 months after operation. There are few studies examining the relationship between survival and the early postoperative EF. Dubroff and associates [43] analyzed changes in ventricular size and function before and immediately after AVR for AR and documented that EF falls after cardiopulmonary bypass for valve replacement, but this study did not examine late clinical outcomes. Others have observed the same phenomenon of an initial fall in EF immediately after valve replacement for AR [21, 43–47].

The prognostic impact of this early change in EF has also not been well studied. In our cohort, there was a decrease in mean EF postoperatively, but late survival was not related to the magnitude of decrease in EF or the absolute value of the early postoperative EF. It is possible that differences in survival might be apparent with additional follow-up. Importantly, late recovery of EF to a normal range was influenced by both the preoperative EF and LV dimensions. This reemphasizes the need to advise undergoing an operation before deterioration in LV function or significant LV enlargement to best allow for good late heart function.

A limitation of this study includes the lack of echocardiographic data for all patients at all time points. As in most clinical studies, test results may not be available because they were performed at another institution, another modality such as cardiac catheterization or magnetic resonance imaging may have been used, or the patient did not receive an echocardiogram at the follow-up interval. In our study, echocardiography was available preoperatively in 94%, predismissal in 90%, and at late follow-up in 56%. In 147 patients (49%), measurements of EF were available at all points.

In patients who received an AVR for AR, decreased LVEF and increased LV dimensions were not associated with late mortality. However, larger indexed LV systolic and diastolic dimensions were associated with late mortality. In our study, the best discrimination in survival was seen at 20 mm/m2 for indexed LVESD and 30 mm/m2 for indexed LVEDD. Indications for operation in patients with AR should reflect the importance of indexed values. Preservation of late EF is best if the operation is performed in patients with normal preoperative LV function.


   Discussion
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comments
 Discussion
References
 
DR KEVIN D. ACCOLA (Orlando, FL): Outstanding presentation, Dr Brown. As always, your center has contributed such important studies to our knowledge of valve surgery. Timing of aortic valve replacement for aortic insufficiency, particularly moderate insufficiency, remains somewhat controversial though yet. Certainly when the surgeon is faced with a decompensated left ventricle and poor ventricular function, these cases can be some of the most challenging cases to not only treat intraoperatively but care for perioperatively and postoperatively. So again, I commend your results. The authors have demonstrated in cases with moderately preserved left ventricular ejection fraction and ventricular function that the results can be quite satisfying.

There are some concerns I have with your paper as well as for the authors. The mean preoperative left ventricular ejection fraction was 56%, which is actually a very well preserved or well-compensated group of patients. I wish I could always see 56% ejection fractions with these patients with aortic insufficiency. The question is, did you consider the extremes of left ventricular ejection fraction, which I noticed you did in one of your slides, but for early and late survival, as well as how this relates to indexed left ventricular end-systolic and end-diastolic dimensions regarding early and late survival, how this compared?

My second concern, although understandably difficult to always obtain, is your postoperative echo follow-up was only around 56% of patients, and do you feel that this may have an effect on your final conclusions and how this relates to not only ejection fraction but end-systolic and end-diastolic dimension changes?

My third question is, were there any concerns and did you evaluate your cohort of patients for any patient-prosthetic mismatch that may have occurred? Because I personally feel that especially in patients with decompensated left ventricles and aortic insufficiency that this particularly has to be avoided. And so did you look at any of the valve options and choices that you made and how this related to your outcomes?

I did enjoy your paper and, as always, appreciated receiving the manuscript quite early. I may suggest one addition to your conclusions, because I think this is a very valuable contribution to our literature with aortic insufficiency, much as it relates to early repair of mitral valve, which was discussed earlier in this session, but I feel your data supports this, and that is, earlier referral of patients with moderate aortic insufficiency and yet compensated left ventricular function should be encouraged and prior to any significant left ventricular end-systolic or end-diastolic dimension enlargement.

Again, I thank the Association for the privilege to discuss the paper on the floor. Thank you, Dr Brown.

DR BROWN: Thank you. To answer your first question about our patients' preoperative ejection fraction, we did try to look at the extremes of function. However, as you have noted, we are somewhat limited by the number of patients who had extreme left ventricular failure or extremely large left ventricular dimensions, and we were not able to make any further conclusions about this subgroup.

Second, in terms of the postoperative follow-up and their echocardiograms, it is a limitation that we are only able to review approximately 56% of late echocardiograms. However, as the echocardiograms were performed for clinical indications, that is all we were able to attain. Whether or not it does have an effect on our outcomes, it is impossible for me to determine. You can speculate that perhaps patients who are doing very well do not have echocardiograms, but you can also speculate that those who have died do not have echos. Unfortunately, it is impossible for me to know.

In relation to patient-prosthesis mismatch, we actually currently are looking at that in this group of patients. There were a very small number who did have patient-prosthesis mismatch, but we feel it is a very rare occurrence in aortic regurgitation because there is often a large aortic root.

As well, in terms of the conclusions regarding early referral, we agree with you completely that early referral is a very good idea and that we should encourage our cardiology colleagues to send patients earlier rather than later.

Thank you.

DR MICHAEL MACK (Dallas, TX): Although I agree with your conclusion, it seems to me that you are missing a control group. If you state that earlier referral should occur, then there needs to be some comparison as to how they do without surgery. It seems to me that it would be appropriate to do what was done in Loma Linda with patients with aortic stenosis and in Michigan with patients with functional mitral regurgitation and review the echo lab for patients with moderate or severe aortic regurgitation that were not operated on for whatever reason and propensity match them as a control group to demonstrate that earlier referral results in improved survival or outcomes or left ventricular dimensions compared to a nonsurgical control cohort.

DR BROWN: Thank you for the suggestion. Our institution has published a natural history study on aortic regurgitation in 1999, and in that study they also found that an indexed left ventricular end-systolic dimension of 25 mm was predictive of poor outcome in unoperated patients with severe aortic regurgitation. So it is a similar finding to what we found. But thank you for the suggestion.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comments
 Discussion
 References
 

  1. American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Thoracic SurgeonsBonow RO, Carabello BA, Kanu C, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons Circulation 2006;114:e84-e231.[Free Full Text]
  2. Bonow RO, Rosing DR, McIntosh CL, et al. The natural history of asymptomatic patients with aortic regurgitation and normal left ventricular function Circulation 1983;68:509-517.[Free Full Text]
  3. Scognamiglio R, Fasoli G, Dalla VS. Progression of myocardial dysfunction in asymptomatic patients with severe aortic insufficiency Clin Cardiol 1986;9:151-156.[Medline]
  4. Siemienczuk D, Greenberg B, Morris C, et al. Chronic aortic insufficiency: factors associated with progression to aortic valve replacement Ann Intern Med 1989;110:587-592.[Abstract/Free Full Text]
  5. Bonow RO, Lakatos E, Maron BJ, Epstein SE. Serial long-term assessment of the natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function Circulation 1991;84:1625-1635.[Abstract/Free Full Text]
  6. Scognamiglio R, Rahimtoola SH, Fasoli G, Nistri S, Dalla VS. Nifedipine in asymptomatic patients with severe aortic regurgitation and normal left ventricular function N Engl J Med 1994;331:689-694.[Medline]
  7. Tornos MP, Olona M, Permanyer-Miralda G, et al. Clinical outcome of severe asymptomatic chronic aortic regurgitation: a long-term prospective follow-up study Am Heart J 1995;130:333-339.[Medline]
  8. Ishii K, Hirota Y, Suwa M, Kita Y, Onaka H, Kawamura K. Natural history and left ventricular response in chronic aortic regurgitation Am J Cardiol 1996;78:357-361.[Medline]
  9. Borer JS, Hochreiter C, Herrold EM, et al. Prediction of indications for valve replacement among asymptomatic or minimally symptomatic patients with chronic aortic regurgitation and normal left ventricular performance Circulation 1998;97:525-534.[Abstract/Free Full Text]
  10. Tarasoutchi F, Grinberg M, Spina GS, et al. Ten-year clinical laboratory follow-up after application of a symptom-based therapeutic strategy to patients with severe chronic aortic regurgitation of predominant rheumatic etiology J Am Coll Cardiol 2003;41:1316-1324.[Abstract/Free Full Text]
  11. Evangelista A, Tornos P, Sambola A, Permanyer-Miralda G, Soler-Soler J. Long-term vasodilator therapy in patients with severe aortic regurgitation N Engl J Med 2005;353:1342-1349.[Medline]
  12. Forman R, Firth BG, Barnard MS. Prognostic significance of preoperative left ventricular ejection fraction and valve lesion in patients with aortic valve replacement Am J Cardiol 1980;45:1120-1125.[Medline]
  13. Henry WL, Bonow RO, Borer JS, et al. Observations on the optimum time for operative intervention for aortic regurgitation, I: evaluation of the results of aortic valve replacement in symptomatic patients Circulation 1980;61:471-483.[Abstract/Free Full Text]
  14. Cunha CL, Giuliani ER, Fuster V, Seward JB, Brandenburg RO, McGoon DC. Preoperative M-mode echocardiography as a predictor of surgical results in chronic aortic insufficiency J Thorac Cardiovasc Surg 1980;79:256-265.[Abstract]
  15. Greves J, Rahimtoola SH, McAnulty JH, et al. Preoperative criteria predictive of late survival following valve replacement for severe aortic regurgitation Am Heart J 1981;101:300-308.[Medline]
  16. Kumpuris AG, Quinones MA, Waggoner AD, Kanon DJ, Nelson JG, Miller RR. Importance of preoperative hypertrophy, wall stress and end-systolic dimension as echocardiographic predictors of normalization of left ventricular dilatation after valve replacement in chronic aortic insufficiency Am J Cardiol 1982;49:1091-1100.[Medline]
  17. Gaasch WH, Carroll JD, Levine HJ, et al. Chronic aortic regurgitation: prognostic value of left ventricular end-systolic dimension and end-diastolic radius/thickness ratio J Am Coll Cardiol 1983;1:775-782.[Abstract]
  18. Fioretti P, Roelandt J, Bos RJ, et al. Echocardiography in chronic aortic insufficiency: is valve replacement too late when left ventricular end-systolic dimension reaches 55 mm? Circulation 1983;67:216-221.[Abstract/Free Full Text]
  19. Stone PH, Clark RD, Goldschlager N, Selzer A, Cohn K. Determinants of prognosis of patients with aortic regurgitation who undergo aortic valve replacement J Am Coll Cardiol 1984;3:1118-1126.[Abstract]
  20. Bonow RO, Picone AL, McIntosh CL, et al. Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: impact of preoperative left ventricular function Circulation 1985;72:1244-1256.[Abstract/Free Full Text]
  21. Bonow RO, Dodd JT, Maron BJ, O'Gara PT, White GG, McIntosh CL, Clark RE, Epstein SE. Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation Circulation 1988;78:1108-1120.[Abstract/Free Full Text]
  22. Daniel WG, Hood WP Jr, Siart A, et al. Chronic aortic regurgitation: reassessment of the prognostic value of preoperative left ventricular end-systolic dimension and fractional shortening. Circulation 985;71:669–80.
  23. Cormier B, Vahanian A, Luxereau P, Kassab R, Acar J. Should asymptomatic or mildly symptomatic aortic regurgitation be operated on? Z Kardiol 1986;75(Suppl 2):141-145.[Medline]
  24. Sheiban I, Trevi GP, Casarotto D, et al. Aortic valve replacement in patients with aortic incompetence: preoperative parameters influencing long-term results Z Kardiol 1986;75(Suppl 2):146-154.[Medline]
  25. Carabello BA, Usher BW, Hendrix GH, Assey ME, Crawford FA, Leman RB. Predictors of outcome for aortic valve replacement in patients with aortic regurgitation and left ventricular dysfunction: a change in the measuring stick J Am Coll Cardiol 1987;10:991-997.[Abstract]
  26. Taniguchi K, Nakano S, Hirose H, et al. Preoperative left ventricular function: minimal requirement for successful late results of valve replacement for aortic regurgitation J Am Coll Cardiol 1987;10:510-518.[Abstract]
  27. Michel PL, Iung B, Abou JS, et al. The effect of left ventricular systolic function on long term survival in mitral and aortic regurgitation J Heart Valve Dis 1995;4(Suppl 2):S160-S168.[Medline]
  28. Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB. Surgery for aortic regurgitation in women Circulation 1996;94:2472-2478.[Abstract/Free Full Text]
  29. Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB. Aortic regurgitation complicated by extreme left ventricular dilation: long-term outcome after surgical correction J Am Coll Cardiol 1996;27:670-677.[Abstract]
  30. Turina J, Milincic J, Seifert B, Turina M. Valve replacement in chronic aortic regurgitation: true predictors of survival after extended follow-up Circulation 1998;98(Suppl):II-100-II-106.
  31. Tornos P, Sambola A, Permanyer-Miralda G, Evangelista A, Gomez Z, Soler-Soler J. Long-term outcome of surgically treated aortic regurgitation: influence of guideline adherence toward early surgery J Am Coll Cardiol 2006;47:1012-1017.[Abstract/Free Full Text]
  32. Lan RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Echocardiography J Am Soc Echocardiogr 2005;18:1440-1463.[Medline]
  33. Chaliki HP, Mohty D, Avierinos JF, et al. Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function Circulation 2002;106:2687-2693.[Abstract/Free Full Text]
  34. Sambola A, Tornos P, Ferreira-Gonzalez I, Evangelista A. Prognostic value of preoperative indexed end-systolic left ventricle diameter in the outcome after surgery in patients with chronic aortic regurgitation Am Heart J 2008;155:1114-1120.[Medline]
  35. Schwartz F, Flameng W, Langebartels F, Sesto M, Walter P, Schlepper M. Impaired left ventricular function in chronic aortic valve disease: survival and function after replacement by Bjork-Shiley prosthesis Circulation 1979;60:48-58.[Abstract/Free Full Text]
  36. Dujardin KS, Enriquez-Sarano M, Schaff HV, et al. Mortality and morbidity of aortic regurgitation in clinical practice: a long-term follow-up study Circulation 1999;99:1851-1857.[Abstract/Free Full Text]
  37. Enriquez-Sarano, Tajik A. Aortic regurgitation N Engl J Med 2004;351:1539-1546.[Medline]
  38. McGoon MD, Fuster V, McGoon DC, Pumphrey CW, Pluth JR, Elveback LR. Aortic and mitral valve incompetence: long-term follow-up (10 to 19 years) of patients treated with the Starr-Edwards prosthesis J Am Coll Cardiol 1984;3:930-938.[Abstract]
  39. Borer JS, Bonow RO. Contemporary approach to aortic and mitral regurgitation Circulation 2003;108:2432-2438.[Free Full Text]
  40. Lung B, Gohlke-Barwolf C, Tornos P, et al. Recommendations on the management of the asymptomatic patient with valvular heart disease Eur Heart J 2002;23:1252-1266.[Medline]
  41. St. John Sutton M, Plappert T, Spiegel A, et al. Early postoperative changes in left ventricular chamber size, architecture, and function in aortic stenosis and aortic regurgitation and their relation to intraoperative changes in afterload: a prospective two-dimensional echocardiographic study Circulation 1987;76:77-89.[Abstract/Free Full Text]
  42. Kang H, Kim Y, Sohn D, et al. Prediction of postoperative left ventricular systolic function with Doppler-derived dP/dt in patients with chronic aortic regurgitation J Am Soc Echocardiogr 2003;16:1111-1115.[Medline]
  43. Dubroff JM, Clark MB, Wong CYH, Spotnitz AJ, Collins RH, Spotnitz HM. Left ventricular ejection fraction during cardiac surgery: a two-dimensional echocardiographic study Circulation 1983;68:95-108.[Abstract/Free Full Text]
  44. Jin XY, Pepper JR, Gibson DG, Yacoub MH. Early changes in the time course of myocardial contraction after correcting aortic regurgitation Ann Thorac Surg 1999;67:139-145.[Abstract/Free Full Text]
  45. Gaasch WH, Andrias CW, Levine H. Chronic aortic regurgitation: the effect of aortic valve replacement on left ventricular volume, mass and function Circulation 1978;58:825-836.[Abstract/Free Full Text]
  46. Boucher CA, Bingham JB, Osbakken, MD, et al. Early changes in left ventricular size and function after correction of left ventricular volume overload Am J Cardiol 1981;47:991-1004.[Medline]
  47. Skarvan K, Zubert M, Seeberger M, Stultz P. Immediate effects of aortic valve replacement on left ventricular function and its determinants Eur J Anaesthesiol 1999;16:659-668.[Medline]



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M. L. Brown, H. V. Schaff, R. M. Suri, Z. Li, T. M. Sundt, J. A. Dearani, and M. Enriquez-Sarano
Regression in left ventricular mass after aortic valve replacement for chronic aortic regurgitation is unrelated to prosthetic valve size
J. Thorac. Cardiovasc. Surg., August 1, 2011; 142(2): e5 - e9.
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