Optimizing timing of surgical correction in patients with severe aortic regurgitation: Role of symptoms

Objectives. We sought to determine the independent effect of preoperative symptoms on survival after surgical correction of aortic regurgitation (AR). Background. Aortic valve replacement for severe AR is recommended after New York Heart Association functional class III or IV symptoms develop. However, whether severe preoperative symptoms have a negative influence on postoperative survival remains controversial. Methods. Preoperative characteristics and postoperative survival in 161 patients with functional class I or II symptoms(group 1) were compared with those in 128 patients with class HI or IV symptoms (group 2) undergoing surgical repair of severe isolated AR between 1980 and 1989. Results. Compared with group 1, group 2 patients were older (p < 0.0001), were more often female (p = 0.001) and more often had a history of hypertension (p = 0.001), diabetes mellitus (p = 0.029) or myocardial infarction (p = 0.005) and were more likely to require coronary artery bypass graft surgery (p < 0.0001). The operative mortality rate was higher in group 2 (7.8%) than in group 1 (1.2%, p = 0.005), and the 10-year postoperative survival rate was worse (45% ± 5% [group 2] vs. 78% ± 4% [group 1], p < 0.0001). Compared with age- and gender-matched control subjects, long-term postoperative survival was similar to that expected in group 1 (p =0.14) but significantly worse in group 2 (p < 0.0001). On multivariate analysis, functional class III or IV symptoms were significant independent predictors of operative mortality (adjusted odds ratio 5.5, p = 0.036) and worse long-term postoperative survival (adjusted hazard ratio 1.81, p = 0.0091). Conclusions. In the setting of severe AR, preoperative functional class III or IV symptoms are independent risk factors for excess immediate and long-term postoperative mortality. The presence of class II symptoms should be a strong incentive to consider immediate surgical correction of severe AR.