Clinical Journey for Patients with Aortic Regurgitation: A Retrospective Observational Study From a Multicenter Database

BACKGROUND

• Guidelines for management of aortic regurgitation (AR) suggest grading severity of disease using echocardiographic criteria ^1,2
• Contemporary data on evaluation rates, aortic valve replacement (AVR) rates, and untreated mortality for patients stratified by degree of AR severity are lacking
  • Prior literature to date has primarily focused on outcomes and/or treatment rates in
    moderate to severe and/or severe AR ^2,3

METHODS

• De-identified real-world dataset (Jan 2018-Mar 2023) of 1,002,853 patients >18 years of age from 25 US institutions participating in the egnite Database (egnite, Inc., Aliso Viejo, CA, USA) with appropriate permissions
• Outcomes: 2-year rates of evaluation by the Heart Team, rates of treatment with AVR, and mortality without AVR were assessed using Kaplan Meier estimates (results compared via log rank test)
  • Physicians were prespecified at the site level as members of the Heart Team

RESULTS

• Of the 1,002,853 patients, 845,113 had documented AR severity and were included in the main study analyses
• Median (interquartile range) time from index to death or censor was 405 (112-808) days
• Rates of evaluation by the Heart Team (95% confidence interval [CI]) at 2 years appeared low for patients with moderate-to-severe or severe AR
  • 65.4% (63.3%-67.4%) for patients diagnosed with severe AR
  • 43.5% (41.7%-45.3%) for patients diagnosed with moderate-to-severe AR

• Rates of AVR (95% CI) at 2 years also were low for patients with moderate-to-severe or severe AR
  • 46.5% (44.2%-48.8%) for patients diagnosed with severe AR
  • 19.4% (17.6%-21.1%) for patients diagnosed with moderate-to-severe AR

• Mortality for patients not treated with AVR increased with greater AR severity
• At 2 years, mortality (95% CI) was 20.7% (18.4%-23.0%) for patients with severe AR
• Two-year mortality (95% CI) for untreated patients with a left ventricular end systolic dimension index (LVESDi) ≤25 mm/m²:
  • 17.1% (16.2%-18.19%) in moderate AR
  • 22.9% (19.3%-26.3%) for severe AR
• For those with an LVESDi >25 mm/m²:
  • 34.3% (29.2%-39.1%) in moderate AR
  • 37.2% (24.9%-47.5%) in severe AR

CONCLUSIONS

• Untreated patients with at least moderate AR may have poor clinical outcomes
  • Left ventricular dilatation (LVESDi >25 mm/m²) appears associated with substantial mortality, even with AR graded as “moderate”
  • These data suggest that earlier referral and assessment by the Heart Team could be beneficial
• Despite the presence of clinically significant AR, patients are infrequently referred to the Heart Team
• Further studies are needed to determine the timing of intervention and the most optimal management of these patients