Circulation, Vol 84, 1625-1635, Copyright © 1991 by American Heart Association
RO Bonow, E Lakatos, BJ Maron and SE Epstein
BACKGROUND. Many asymptomatic patients with aorta regurgitation and normal
left ventricular systolic function remain clinically stable for many years,
but others ultimately develop symptoms or left ventricular dysfunction and
require operation. To identify indexes of left ventricular function
predictive of symptomatic and functional deterioration during the long-term
course of asymptomatic patients, we studied 104 asymptomatic patients with
chronic severe aortic regurgitation and normal left ventricular ejection
fraction at rest. METHODS AND RESULTS. Serial echocardiographic (average,
7.8 per patient) and radionuclide angiographic (average, 5.0 per patient)
studies were obtained over a mean follow-up period of 8 years (range, 2- 16
years). By Kaplan-Meier life table analysis, 58 +/- 9% of patients remained
asymptomatic with normal ejection fraction at 11 years, an average
attrition rate of less than 5% per year; two patients died suddenly, four
developed asymptomatic left ventricular dysfunction, and 19 underwent
operation because symptoms developed. By univariate Cox regression
analysis, many variables on initial study were associated with death,
ventricular dysfunction, or symptoms, including age, left ventricular
end-systolic dimension and end-diastolic dimension, fractional shortening,
and both rest and exercise ejection fraction (all p less than 0.001). The
average rates of change of rest ejection fraction, fractional shortening,
and end-systolic dimension were also associated with death or symptoms by
univariate Cox analysis (all p less than 0.01). However, when all variables
were included in a multivariate Cox analysis, only age (p less than 0.05),
initial end- systolic dimension (p less than 0.001), and rate of change in
end- systolic dimension and rest ejection fraction during serial studies
(both p less than 0.05) predicted outcome. CONCLUSIONS. Thus, in addition
to indexes of left ventricular function determined on initial evaluation,
serial long-term changes in systolic function identify patients likely to
develop symptoms and require operation. Patients have a higher risk of
symptomatic deterioration if there is progressive change in end-systolic
dimension or resting ejection fraction during the course of serial studies.
ARTICLES
Serial long-term assessment of the natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function
Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892.
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