Systolic dysfunction in aortic regurgitation

Is intervention still worth it?

Aortic regurgitation leads to chronic volume overload to the LV, which is in a situation of high preload and afterload. In an adaptive manner, there is dilation of the cavity that in advanced stages may present decompensation and start a process of loss of systolic function. As recently discussed here on our platform, the ideal time to intervene would be a stage prior to the drop in the ejection fraction or even at a time when the changes may still be reversible.

Currently, patients with advanced LV dilations have an indication for intervention, even when asymptomatic, although this is not unanimous.  What we fear the most is to miss the proper procedure timing and evolve with extensive fibrosis and loss of myocardial contractile function.

We know the fall in LVEF has a negative impact on long-term survival in patients with major aortic regurgitation. In addition, in short term, those with significant dysfunction have high 30-day mortality, although a center of technical excellence can reduce the impacts of these numbers.

Much has been researched about predictive factors for recovery from LVEF with surgical treatment. We know that around 1/3 of the patients do not recover either in diameter or in LVEF. However, during the postoperative period, we observe a decrease in the preload and in the afterload, which leads to less stress on the LV, generating a situation conducive to better systolic performance.

In summary, we have that the decrease in LVEF in patients with AR brings a worse long-term prognosis, but once this has occurred, the early correction brings greater possibilities of recovery of the contractile function, being then indicated, except in stages terminals with extensive fibrosis and left ventricular systolic dysfunction.

Suggested literature:

1 – Murashita T, Schaff HV, Suri RM, et al. Impact of Left Ventricular Systolic Function on Outcome of Correction of Chronic Severe Aortic Valve Regurgitation: Implications for Timing of Surgical Intervention. Ann Thorac Surg. 2017 Apr;103(4):1222-1228.

 

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