Decision making in asymptomatic aortic regurgitation in the era of guidelines: incremental values of resting and exercise cardiac dysfunction

Background- The decision-making role of exercise echocardiography in the surgical timing for aortic regurgitation remains a matter of debate because of limited data on its link with outcome. The aim of this study was to assess the role of echocardiographic measurements at rest and during exercise as predictors of valve surgery in asymptomatic aortic regurgitation. Methods and Results- Comprehensive resting and exercise echocardiography was performed in 159 consecutive patients (50±15 years; 80% male) with isolated moderately severe to severe aortic regurgitation and preserved left ventricular (LV) function (LV ejection fraction >50%, LV end-diastolic dimension ≤70 mm, LV end-systolic dimension ≤50 mm or ≤25 mm/m(2)) in whom initial management was expectant. Echocardiographic measurements were performed at rest and during exercise. LV and right ventricular (RV) longitudinal strain was analyzed at rest using velocity vector imaging. Valve surgery was performed in 50 patients (31%) during 30±21 months. After adjustment for age and sex in a multivariable Cox proportional-hazards model, exercise tricuspid annular plane systolic excursion (TAPSE; hazards ratio [HR], 0.48; P=0.001) was associated with valve surgery-free, independent of resting LV strain (HR, 1.63; P=0.005), exercise LV end-diastolic volume (HR, 1.38; P=0.048), and resting RV strain (HR, 1.69; P=0.002). In sequential Cox models, a model based on clinical data (χ(2), 20.4) was improved by resting LV strain (χ(2), 30.1; P=0.001), resting RV strain (χ(2), 49.7; P<0.001), and further increased by exercise TAPSE (χ(2), 64.4; P<0.001). Conclusions- In asymptomatic aortic regurgitation, resting LV strain, resting RV strain, and exercise TAPSE were independently associated with the need for earlier aortic surgery.