New multicenter data published in JAMA suggests that surgery for aortic regurgitation may need to be done earlier than current guidelines recommend, with lower LV size thresholds and possibly different cutoffs for men and women.
- LVESDi and LVESVi (Left Ventricular End-Systolic Diameter/Volume Index) are echocardiographic measurements that assess heart function and predict HF risk.
- Current guidelines recommend aortic valve surgery using uniform LVESDi thresholds (25 mm/m²) regardless of patient sex with a single 45 mL/m² LVESVi threshold.
- Although LV enlargement is a common sign of aortic regurgitation, it’s uncertain whether diameter or volume is more important, and if sex-specific thresholds help.
Studying several cohorts, researchers followed 808 patients with symptomatic AR and preserved LVEF with a median 7-year follow-up examining mortality rates after medication and valve surgery, revealing some critical differences between men and women.
- Average baseline LVESDi was identical between sexes (both 20 mm/m²), whereas men had larger average LVESVi (39 vs 31 mL/m²).
- During medical management, 74 patients died with the survival rate significantly lower in women (80% vs 89%), due to too high of a threshold for surgery.
- Meanwhile, a threshold of LVESDi ≥20 mm/m² for both sexes led to much higher mortality risk than expected (guidelines recommend surgery at 25 mm/m²).
- After surgery, survival rates were similar between the sexes (85% women vs 89% men), suggesting timely surgery eliminates the medication survival gap.
So what to do with all this data? Well, it might be time to reconsider current guidelines, since they might actually disadvantage women by applying sex-neutral criteria that don’t account for their different cardiac remodeling patterns, a problem that we’ve also seen in HF management for women.
- On the bright side, European guidelines recently incorporated LVESVi with a 45 mL/m² threshold, but this analysis demonstrates women need a lower 40 mL/m² cutoff.
The Takeaway
Although complex, this study suggests that lower LV enlargement thresholds and sex-specific volume cutoffs may allow earlier identification of high-risk patients, particularly women. That’s important considering they face higher mortality with medical management, which appears to be driven by delayed surgery rather than differences in survival following the operation.
