Left ventricular dilatation in patients with significant aortic regurgitation: association with outcome

Aims: Left ventricular (LV) dilatation is an important prognostic factor in patients with aortic regurgitation (AR). Although current guidelines recommend the use of LV end-systolic diameter index (LVESDi) to indicate the need for intervention, recent studies suggested that LV end-systolic volume index (LVESVi) may more accurately characterize LV remodelling. The present study aims to evaluate, in a multi-centre setting, whether combining LV linear and volumetric measures could improve risk stratification. Methods and results:  A total of 1070 patients (56 +/- 18 years, 65% male) with significant AR were included. Cut-off values of 20 mm/m(2) for LVESDi and 45 mL/m(2) for LVESVi were used to identify the following groups: no-significant LV dilatation (n = 485), when both LVESDi and LVESVi were below the cut-off values; discordant LV dilatation (n = 279) if only one positive criterium was present; and concordant LV dilatation (n = 306) when both LVESDi and LVESVi were enlarged. The primary endpoint was all-cause mortality. During a median follow-up of 7.4 (IQR, 4.5-11) years, 168 patients (16%) died, and 484 (45%) underwent aortic valve surgery (AVS). Patients with concordant LV dilatation showed the worst 10-year survival (P < 0.001). Discordant (HR 2.066, 95% CI 1.295-3.298; P = 0.002) or concordant LV dilatation (HR 2.759, 95% CI 1.616-4.710; P < 0.001) was independently associated with higher mortality compared with patients with no-significant LV dilatation after adjusting for relevant clinical and echocardiographic variables and regardless of AR severity. However, both groups showed greater benefit from AVS. LV dilatation, either concordant or discordant, was also independently associated with outcome in asymptomatic patients and those with left ventricular ejection fraction > 55%. Conclusion: In patients with significant AR, the presence of LV dilatation detected by linear and/or volumetric measures was independently associated with increased mortality.