Observations on the optimum time for operative intervention for aortic regurgitation. II. Serial echocardiographic evaluation of asymptomatic patients.

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Abstract
Symptomatic patients with aortic valve replacement for isolated aortic regurgitation were studied using echocardiography. Patients in whom preoperative left ventricular end-systolic dimension (LVD[SYS]) exceeded 55 mm or fractional shortening (%FS) was less than 25% were at high risk of developing congestive heart failure and dying after an otherwise successful operation. Since indices of left ventricular systolic function might identify asymptomatic patients with aortic regurgitation who might benefit from earlier operation, 37 such patients were evaluated with serial echocardiograms (mean follow-up 34 mo.). Patients (14) (38%) subsequently developed symptoms and were recommended for operation (SUBSQ OP). Patients (23) (62%) remain asymptomatic during follow-up (NON OP). LVD(SYS) and %FS were the most sensitive measurements for distinguishing on initial examination the patients requiring operation from those who have not (LVD[SYS] 53.0 mm SUBSQ OP vs. 44.3 mm NON OP, P = 0.001; %FS 28.8% SUBSQ OP vs. 33.9% NON OP, P = 0.002). During serial studies, the maximum rate of change in end-systolic dimension exceeded 7 mm/yr in only 1 patient. Of 5 patients, 4 (80%) with end-systolic dimension greater than 55 mm developed symptoms and came to operation during a mean follow-up of 39 mo. Of the 20 patients whose initial end-systolic dimension was 50 mm or less, only 4 patients (20%) developed symptoms and required operation, and none died during follow-up. An asymptomatic patient with aortic regurgitation and an end-systolic dimension less than 50 mm is apparently at low risk and can be safely followed with echocardiograms at yearly intervals. Asymptomatic patients with end-systolic dimension of 50-54 mm are being followed with serial echocardiograms every 4-6 mo. Operation is recommended to patients with end-systolic dimensions of 55 mm or greater, even in the absence of symptoms.

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