The management of patients with aortic regurgitation and severe left ventricular dysfunction: a systematic review

Abstract

A systematic search of Medline, EMBASE and CINAHL electronic databases was performed. Original research articles reporting all-cause mortality following surgery in patients with aortic regurgitation and severe left ventricular systolic dysfunction (LVSD) were identified. Nine of the 10 eligible studies were observational, single-center, retrospective analyses. Survival ranged from 86 to 100% at 30 days; 81 to 100% at 1 year and 68 to 84% at 5 years. Three studies described an improvement in mean left ventricular ejection fraction (LVEF) following aortic valve replacement (AVR) of 5–14%; a fourth study reported an increase in mean left ventricular ejection fraction (LVEF) of 9% in patients undergoing isolated AVR but not when AVR was combined with coronary artery bypass graft and/or mitral valve surgery. Three studies demonstrated improvements in functional New York Heart Association (NYHA) class following AVR. Additional studies are needed to clarify the benefits of AVR in patients with more extreme degrees of left ventricular systolic dysfunction (LVSD) and the potential roles of cardiac transplantation and transaortic valve implantation.

Keywords:

• aortic regurgitation
• aortic valve replacement
• cardiac transplantation
• left ventricular dysfunction
• transcatheter aortic valve replacement
• valvular heart disease

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Patients with aortic regurgitation (AR) and severe left ventricular systolic dysfunction (LVSD) are at high risk of adverse outcomes.

• Patients with AR and severe LVSD are often managed conservatively. <3% of patients with AR undergoing aortic valve replacement (AVR) had severe LVSD in the Euro Heart Survey and only one-third of all patients with AR and severe LVSD in one single-center study ultimately underwent surgery.

• No randomized controlled trials have investigated the use of surgery (or other treatment modalities) in this population.

• In retrospective, mainly single-center analyses, AVR is associated with satisfactory short- to medium-term survival in patients with AR and severe LVSD (86–100% at 30 days; 81–100% at 5 years and 68–84% at 5 years).

• Three studies described an improvement in mean aortic valve replacement following AVR ranging from 5 to 14%; a fourth study reported an increase in mean left ventricular ejection fraction of 9% but only in patients undergoing isolated AVR (as opposed to AVR combined with CABG and/or mitral valve surgery). Three studies also demonstrated a marked improvement in functional NYHA class following AVR.

• With advances in surgical techniques, anesthetic care and heart failure therapy, the prognosis of patients with AR and severe LVSD can be expected to improve further.

• No studies have specifically investigated the role of cardiac transplantation or transaortic valve implantation in patients with AR and severe LVSD.

• Additional studies are needed to investigate the role of AVR in patients with other high-risk features including more extreme LVSD, as well as the roles of transaortic valve implantation and cardiac transplantation.

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