Challenging sacred cows: does left ventricle end-systolic and end-diastolic diameter change significantly in long term follow up of patients with severe aortic regurgitation ?

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Abstract Background American and European valvular heart disease guidelines suggest considering aortic valve surgery in patients with severe aortic regurgitation (AR) and progressive increase in left ventricle (LV) end diastolic diameter (LVEDD) into the severe range or progressive decrease in LV function. Surprisingly, there are almost no studies that actually examined systematically the rate of change over time in these widely used parameters in clinical practice in patients with severe AR. Purpose determine the rate of change in LVEDD, left ventricular end systolic diameter (LVESD) and fractional shortening (FS) in patients with significant AR over a long period of time. Methods we considered all consecutive patients with at least moderate to severe AR on index transthoracic echo study and at least four subsequent echo studies over a follow-up period longer than 1.5 years in a large tertiary hospital registry between April 1994 and April 2024. Exclusion criteria were concomitant greater than mild to moderate aortic stenosis or mitral valve disease, aortic dissection, previous aortic or mitral surgery, hypertrophic cardiomyopathy or complex congenital heart disease on index study. Aortic valve replacement (AVR) or death terminated follow-up in this study. Partial correlation corrected for repeated measures was determined for LVEDD/LVESD/FS and interval period (in days) between repeat studies. Results We included a cohort of 140 patients meeting the inclusion criteria study after excluding 31 patients as per above criteria. Aortic valve was bicuspid in 39 (27.9%) of the patients, and unicuspid in 4 (2.9%) patients. Median follow-up was 4.4 years (interquartile range (IQR) 1.9 to 8.8 years), median interval between consecutive studies was 255 days (IQR 172 to 367 days), 35 (25%) patients died and 61 (43.6%) patients underwent AVR. Partial correlation coefficients and p values for LVEDD, LVESD, and FS were respectively -0.3 (p<0.0001), -0.032 (p=0.24), and -0.18 (p<0.001). Conclusions Contrary to conventional wisdom, we didn’t find a significant trend of dilatation in left ventricular end diastolic and end-systolic LV diameter in patients with ≥ moderate to severe AR over a long follow-up, but a weak trend of fractional shortening decrease over time was noted. These findings cast doubt on the utility attributed to change in these parameters as part of the routine clinical follow up of patients with significant AR. LVEDD and LVESD change over time

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