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Impact of early versus Class-I triggered surgery on postoperative survival in severe aortic regurgitation: An observational study from the AVIATOR registry

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Background and objectives: Class I triggers for severe and chronic aortic regurgitation (AR) surgery rely mainly on symptoms or systolic dysfunction, resulting in a negative outcome despite surgical correction. Therefore, US and European guidelines now advocate for earlier surgery.

We sought to determine whether earlier surgery leads to improved postoperative survival. Methods: We evaluated postoperative survival of patients who underwent surgery for severe AR in the international multicenter registry for aortic valve surgery, AVIATOR, over a median follow-up of 37 months.

Results:Among 1,899 patients (49+-15 years, 85% male), 83% and 84% had Class I indication according to AHA and ESC, respectively, and most were offered repair surgery (92%). Twelve patients (0.6%) died after surgery and 68 within 10 years after the procedure.

Heart failure symptoms (HR=2.60 [1.20,5.66], p=0.016), and either left ventricular end-systolic diameter (LVESD)>50mm or LVESD index (LVESDi)>25mm/m2 (HR=1.64 [1.05,2.55], p=0.030) predicted survival independently over and above age, gender, and bicuspid phenotype. Therefore, patients who underwent surgery based on any Class I trigger had worse adjusted survival.

However, patients who underwent surgery while meeting early imaging triggers (LVESDi 20-25mm/m2 or left ventricular ejection fraction [LVEF] 50-55%) had no significant outcome penalty. Conclusion: In this international registry of severe AR, surgery when meeting Class I triggers led to postoperative outcome penalty, compared with earlier triggers (LVESDi between 20-25mm/m2 or LVEF between 50-55%).

This observation, which applies to expert centers where AV repair is feasible, should encourage the global use of repair techniques and the conduction of randomized trials.