Better postoperative outcome with Class II indications for surgery in Aortic Regurgitation?

Better postoperative outcome with Class II indications for surgery in Aortic Regurgitation?

Are Class II indications for surgery in hemodynamically significant chronic aortic regurgitation better than Class I indications with regards to post operative outcome? So it appears according to a study by Yang LT et al, published in the Journal of American College of Cardiology [1].

According to 2014 AHA/ACC Guideline for the management of patients with valvular heart disease [2], the indications for surgery in dominant aortic regurgitation are as follows:

  1. Symptoms – Class I
  2. Left ventricular ejection fraction less than 50% – Class I
  3. Along with surgery for aortic dilatation or aneurysms – Class I
  4. Left ventricular end-systolic dimension index more than 25 mm/m2 – Class IIa
  5. Left ventricular end systolic dimension more than 50 m – Class IIa
  6. Left ventricular end diastolic dimension more than 65 mm – Class IIb

The authors found that patients with Class I indications for surgery had inferior post-operative survival (p < 0.003). As one would anticipate, they noted that age, comorbidities, baseline symptoms and higher left ventricular systolic dimension index were associated with all cause mortality, all with a p value less than or equal to 0.01. Authors go on to suggest that the Class II indications with better post operative outcome needs higher attention. This is especially important as Class I indications, mainly symptoms, where the most common triggers for aortic valve replacement in the study. It may be noted that Class II indications contributed only 14% of cases of aortic valve replacements.

Authors also highlighted the importance of left ventricular end systolic dimension index (LVESDi) as it is age, sex, and body size neutral. They noted that late mortality was increased in patients who had LVESDi 20 to 25 mm/m2, which is below the threshold for surgery in current guidelines.

Reference

  1. Yang LT, Michelena HI, Scott CG, Enriquez-Sarano M, Pislaru SV, Schaff HV, Pellikka PA. Outcomes in Chronic Hemodynamically Significant Aortic Regurgitation and Limitations of Current Guidelines. J Am Coll Cardiol. 2019 Feb 22. pii: S0735-1097(19)30314-6.
  2. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jun 10;63(22):2438-88.

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