Objectives Although guidelines support aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR) and left ventricular ejection fraction (LVEF) <50%, severe left ventricular dysfunction (LVEF <35%) is thought to confer high surgical risk. We sought to determine if a survival benefit exists with AVR compared with medical management in this high-risk, relatively rare population.
Methods A large institutional echocardiography database was queried to identify patients with severe AR and LVEF <35%. Manual chart review was performed. Due to small sample size and population heterogeneity, corrected group prognosis method was applied, which calculates the adjusted survival curve for each individual using fitted Cox proportional hazard model. Average survival adjusted for comorbidities and age was then calculated using the weighted average of the individual survival curves.
Results Initially, 2 54 614 echocardiograms were considered, representing 1 45 785 unique patients, of which 40 patients met inclusion criteria. Of those, 18 (45.0%) underwent AVR and 22 (55.0%) were managed medically. Absolute mortality was 27.8% in the AVR group and 91.2% in the medical management group. After multivariate adjustment, end-stage renal disease (HR=17.633, p=0.0335) and peripheral arterial disease (HR=6.050, p=0.0180) were associated with higher mortality. AVR was associated with lower mortality (HR=0.143, p=0.0490). Mean follow-up time of the study cohort was 6.58 years, and mean survival for patients undergoing AVR was 6.31 years.
Conclusions Even after adjustment for clinical characteristics and patient age, AVR is associated with higher survival for patients with low LVEF and severe AR. Although treatment selection bias cannot be completely eliminated by this analysis, these results provide some evidence that surgery may be associated with prolonged survival in this high-risk patient group.
- valve disease surgery
- heart failure with reduced ejection fraction
- aortic regurgitation
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Contributors Conception and design of study, AGF, JHW. Acquisition of data, AGF, VB, MMW, JHW. Analysis/interpretation of data, AGF, VB, JHW, MMW. Drafting the manuscript, AGF, VB, EL, MP, MMW, GT, SM, TMS, JHW. Revising the manuscript critically for important intellectual content, AGF, VB, JHW. Approval of the version of the manuscript to be published, AGF, VB, EL, MP, MMW, GT, SM, TMS, JHW.
Funding JHW is supported by a career development award from the National Institutes of Health through Harvard Catalyst (KL2 TR001100).
Competing interests None declared.
Ethics approval Partners Healthcare IRB.
Provenance and peer review Not commissioned; externally peer reviewed.
Correction notice Since this paper was first published online the image labelled figure 1 has now been updated to figure 2. The image which was published as figure 2 is now figure 1. Neither of the figure legends have been altered.
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