Repair of Aortic Regurgitation in Young Adults: Sooner Rather Than Later

Abstract

Background Establishing surgical criteria for aortic valve replacement (AVR) in severe aortic regurgitation in young adults is challenging due to the lack of evidence-based recommendations. We studied indications for AVR in young adults with severe aortic regurgitation and their outcomes, as well as the relationship between presurgical echocardiographic parameters and postoperative left ventricular (LV) size, function, clinical events, and valve-related complications. Methods and Results Data were collected retrospectively on 172 consecutive adult patients who underwent AVR or repair for severe aortic regurgitation between 2005 and 2019 in a tertiary cardiac center (age at surgery 29 [22-41] years, 81% male). One-third underwent surgery before meeting guideline indications. Postsurgery, 65% achieved LV size and function normalization. LV ejection fraction showed no significant change from baseline. A higher presurgical LV end-systolic diameter correlated with a lack of LV normalization (odds ratio per 1-cm increase 2.81, P<0.01). The baseline LV end-systolic diameter cut-off for predicting lack of LV normalization was 43 mm. Pre- and postoperative LV dimensions and postoperative LV ejection fraction predicted clinical events during follow-up. Prosthetic valve-related complications occurred in 20.3% during an average 5.6-year follow-up. Freedom from aortic reintervention was 98%, 96.5%, and 85.4% at 1, 5, and 10 years, respectively. Conclusions Young adult patients with increased baseline LV end-systolic diameter or prior cardiac surgery are less likely to achieve LV normalization after AVR. Clinicians should carefully balance the long-term benefits of AVR against procedural risks and future interventions, especially in younger patients. Evidence-based criteria for AVR in severe aortic regurgitation in young adults are crucial to improve outcomes.

Keywords: aortic regurgitation; aortic valve; congenital heart disease; outcomes; surgery; young.

Figure 1. Patients with chronic AR stratified by the type of guideline indication ([A] 2021 ESC/EATS; [B] 2020 ACC/AHA) for aortic valve surgery present at the time of the surgery.

ACC indicates American College of Cardiology; AHA, American Heart Association; AR, aortic regurgitation; EATCS, European Association for Cardio‐Thoracic Surgery; ESC, European Society of Cardiology; LV, left ventricle; and LVEF, left ventricular ejection fraction.

Figure 2. LV parameters (end‐diastolic diameter, end‐systolic diameter, ejection fraction, end‐diastolic volume, and end‐systolic volume) measured by transthoracic echocardiogram before, immediately after surgery, and at least 6 months postprocedure.

LV indicates left ventricle/ventricular.

Figure 3. ROC curve displaying the sensitivity and specificity of the preoperative LVESD in predicting LVESD normalization after surgery.

The sensitivity and specificity for the optimal cut‐off points are also shown. LVESD indicates left ventricular end‐systolic diameter; ROC, receiver operating characteristic; Sens, sensitivity; and Spec, specificity.

Figure 4. Kaplan–Meier curve presenting freedom from aortic valve reintervention with 95% CIs.