Key Points
• Source: Interactive Cardiovascular and Thoracic Surgery
• Conclusions: “We found a predominantly beneficial effect of early surgery on long-term survival in this specific patient population, and none of the studies demonstrated a disadvantageous effect. Moreover, many patients with an initially conservative strategy eventually proceed to AVR during the follow-up period, in a potentially more advanced disease state, which can affect long-term outcome as well. Therefore, even more longer term follow-up than that provided by the included studies is warranted, to more adequately answer this important matter of debate.”
• This structured best evidence topic in cardiac surgery aimed to answer whether patients with asymptomatic severe aortic regurgitation with preserved ejection fraction benefit from early surgery vs. watchful waiting with regard to long-term survival.
• In the current case, a 53-year-old man with previous mild aortic regurgitation (AR) is noted to progress to severe AR on follow-up. The LVEF is 58% and LVESD is 44 mm. The patient is asymptomatic and can perform intense exercise and is referred to the heart-valve team for clinical management.
• Guidelines recommend follow-up/watchful waiting, although data are mixed.
• The Dutch investigators noted that the presence of bicuspid aortic valve (BAV) and aortic root/ascending aortic diameter are important factors to be considered. These factors have yet to be analyzed separately, per the authors.
• “Older patients especially seem to adapt more poorly to chronic volume overload due to AR, making them potential candidates for a more aggressive approach,” the authors concluded. “However, when a justified watchful waiting strategy is applied, close, extensive monitoring seems to be imperative, because the mere monitoring for development of class I and II triggers seems to lead to improved survival.”