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July 20, 2022

Earlier Intervention in Asymptomatic Chronic Aortic Regurgitation—Novel Indicators of Myocardial Overload

Author Affiliations
  • 1Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
  • 2Division of Cardiovascular Diseases, Northwestern University, Chicago, Illinois
JAMA Cardiol. 2022;7(9):883-884. doi:10.1001/jamacardio.2022.2115

Chronic aortic regurgitation (AR) is characterized by combined left ventricular (LV) volume and pressure overload,1 resulting in a long latent period of progressive but potentially reversible LV enlargement. This period is followed years to decades later by a decrease in ejection fraction (EF) and onset of symptoms.2 To avoid the upfront risk of operation, premature placement of a prosthetic valve, and associated long-term consequences, the recommendation for aortic valve intervention in asymptomatic patients is when the LV end-systolic dimension (ESD) is greater than 50 mm (or indexed dimension >25 mm/m2) and EF is 55% or less.3 These thresholds are based on older studies with limited numbers of patients, which showed that patients had worse long-term outcomes beyond these cutoffs. The suggestion is that once these thresholds are reached, myocardial dysfunction from long-standing pressure and volume overload has already occurred. Now operative risks are lower, newer-generation prostheses are more advanced, and valve repair has been introduced for select patients. Perhaps it is time to look again at the timing of intervention in patients with asymptomatic severe AR.

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