Long-term outcomes of combined significant aortic regurgitation and mitral regurgitation versus isolated aortic regurgitation

Background

Combined aortic regurgitation (AR) and mitral regurgitation (MR) is a relatively common multiple valvular heart disease. Current guidelines recommend intervention (AVI and/or MVI) when either lesion becomes severe in the setting of symptoms, left ventricular (LV) systolic dysfunction or dilation, as in isolated severe AR and MR, but no evidence has been generated specifically for this combination.

Purpose

To compare survival among patients with significant combined AR and MR (≥ moderate AR and ≥ moderate MR) and those with isolated severe AR in a multicenter setting.

Methods

A total of 421 patients (age 66 ± 15 years, 68% male) were included. Of these, 108 had isolated severe AR. Patients with concomitant AR and MR (n=313) were classified into 4 groups according to regurgitation severity: moderate AR with moderate MR (n = 145), moderate AR with severe MR (n = 70), severe AR with moderate MR (n = 46), and severe AR with severe MR (n = 52). Regurgitation severity was determined using a multiparametric approach, in accordance with current ESC/EACVI guidelines. The study endpoint was all-cause mortality, with valve intervention accounted as a time-dependent covariate.

Results

Over a median follow-up of 6 years (IQR 2-10), 147 (35%) patients died. A total of 221 (53%) patients underwent either AVI or MVI. Patients with isolated severe AR were younger, had more prevalence of bicuspid aortic valve (BAV), while patients with moderate AR and MR were older and more often female (Table 1). Patients with severe AR and MR had larger LV dimensions, and those with associated severe MR had more prevalence of atrial fibrillation (AF), primary MR and larger left atrial volume index (LAVI).

After multivariable adjustment for age, New York Heart Association (NYHA) class, hypertension, diabetes, coronary artery disease, AF, BAV, LAVI, LV end-systolic diameter index, LV stroke volume index, tricuspid regurgitation and valve intervention, increasing severity of AR and MR was independently associated with progressively worse survival (Figure 1A). Adjusted survival curves (for the same variables, Figure 1B) showed that patients with combined moderate AR and MR, had survival comparable to patients with isolated severe AR. In contrast, severe AR with moderate or severe MR showed the worst survival (HR 2.98; 95% CI 1.21-7.33; p=0.017 and HR 3.30; 95% CI 1.36-8.04; p=0.009, respectively) (Figure 1B).

Conclusion

Among patients with combined AR and MR, severe degree of any regurgitation is independently associated with worse long-term survival. Interestingly, patients with combined moderate AR and moderate MR have adjusted outcomes comparable to those with isolated severe AR, suggesting the significantly increased risk also of a combined moderate valve disease.Figure 1Figure 2