The natural history of asymptomatic patients with aortic regurgitation and normal left ventricular function.

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Abstract
In asymptomatic patients with severe aortic regurgitation and normal left ventricular function, aortic valve replacement was recommended to preserve left ventricular function. In such patients, however, the natural history without operation is unknown. Serial studies were therefore performed in 77 asymptomatic patients with normal left ventricular ejection fraction at rest as determined by radionuclide angiography and normal left ventricular fractional shortening as determined by echocardiography; 63 patients had 3+ and 4+ aortic regurgitation visualized by aortic root cineangiography, and the other 14 patients had pulse pressures > 70 mm Hg. During mean follow-up of 49 mo. (range 6-114) no patient died and 12 patients underwent aortic valve replacement because of the onset of symptoms (11 patients) or the onset of left ventricular dysfunction without symptoms (1 patient). By life table analysis, the percent of patients who did not require operation was 90 .+-. 3% (.+-. SE) at 3 yr, 81 .+-. 6% at 5 yr and 75 .+-. 7% at 7 yr. In the 12 who did have surgery there were no operative or late deaths (postoperative follow-up 8-75 mo., mean 38), left ventricular ejection fraction increased (45 .+-. 5% (.+-. SD] preoperatively, 58 .+-. 11 postoperatively; P < 0.001), and left ventricular diastolic dimension determined echocardiographically decreased (74 .+-. 4 mm preoperatively, 52 .+-. 5 mm postoperatively; P < 0.001). Thus, in asymptomatic patients with normal left ventricular function, death is rare, and < 4% per yr require aortic valve replacement because symptoms or left ventricular dysfunction develop. When aortic valve replacement is delayed until symptoms or left ventricular dysfunction develop, postoperative survival is excellent, and left ventricular size and function improve postoperatively. Hence, prophylactic aortic valve replacement to preserve left ventricular function should not be performed in asymptomatic patients with severe aortic regurgitation and normal left ventricular function.