PREDICTION OF INDICATIONS FOR VALVE-REPLACEMENT AMONG ASYMPTOMATIC ORMINIMALLY SYMPTOMATIC PATIENTS WITH CHRONIC AORTIC REGURGITATION AND NORMAL LEFT-VENTRICULAR PERFORMANCE

Background-Optimal criteria for valve replacement are unclear in asymp tomatic/minimally symptomatic patients with aortic regurgitation (AR) and normal left ventricular (LV) performance at rest. Moreover, previo us studies have not assessed the prognostic capacity of load-adjusted LV performance (''contractility'') variables, which may be fundamental ly related to clinical state. Therefore, 18 years ago, we set out to t est prospectively the hypothesis that objective noninvasive measures o f LV size and performance and, specifically, of load-adjusted variable s, assessed at rest and during exercise (ex), could predict the develo pment of currently accepted indications for operation for AR. Methods and Results-Clinical variables and measures of LV size, performance, a nd end-systolic wall stress (ESS) were assessed annually in 104 patien ts by radionuclide cineangiography at rest and maximal ex and by echoc ardiography at rest; ESS was derived during ex. During an average 7.3- year follow-up among patients who had not been operated on, 39 of 104 patients either died suddenly (n=4) or developed operable symptoms onl y (n=22) or subnormal LV performance with or without symptoms (n=13) ( progression rate=6.2%/y). By multivariate Cox model analysis, change ( Delta) in LV ejection fraction (EF) from rest to ex, normalized for De lta ESS from rest to ex (Delta LVEF-Delta ESS index), was the stronges t predictor of progression to any end point or to sudden cardiac death alone. Unadjusted Delta LVEF was almost as efficient. Symptom status modified prediction on the basis of the Delta LVEF-Delta ESS index. Th e population tercile at highest risk by Delta LVEF-Delta ESS progresse d to end points at a rate oi 13.3%/y, and the lowest-risk tercile prog ressed at 1.8%/y. Conclusions-Currently accepted symptom and LV perfor mance indications for valve replacement, as well as sudden cardiac dea th, can be predicted in asymptomatic/minimally symptomatic patients wi th AR by load-adjusted Delta LVEF-Delta ESS index, which includes data obtained during exercise.