Outcomes of Watchful Waiting Strategy and Predictors of Postoperative Prognosis in Asymptomatic or Equivocally Symptomatic Chronic Severe Aortic Regurgitation With Preserved Left Ventricular Function

Background The optimal surgical timing for asymptomatic or equivocally symptomatic chronic severe aortic regurgitation with preserved left ventricular ejection fraction remains controversial. Methods and Results Two hundred ten consecutive patients (median age 65 years) with asymptomatic or equivocally symptomatic chronic severe aortic regurgitation and left ventricular ejection fraction ≥50% were registered. First, the treatment plans (aortic valve replacement or watchful waiting) after initial diagnosis were investigated. Then, 2 studies were set: Study A (n=144) investigated the prognosis of patients who were managed under the watchful waiting strategy after initial diagnosis; Study B (n=99) investigated the postoperative prognosis in patients who underwent aortic valve replacement at initial diagnosis or after watchful waiting. The primary outcomes were all‐cause death in Study A and postoperative cardiovascular events in Study B. In Study A, 3 died of noncardiovascular causes during a median follow‐up of 3.2 years. In Kaplan–Meier analysis, the survival curve was similar to that of an age‐sex‐matched general population in Japan. In Study B, 9 experienced the primary outcome during a median follow‐up of 5.0 years. In Cox regression analysis, preoperative left ventricular end‐systolic diameter enlargement (hazard ratio, 1.11; P =0.048) and left ventricular end‐systolic diameter >45 mm (hazard ratio, 12.75; P =0.02) were significantly associated with poor postoperative prognosis. In Kaplan–Meier analysis, left ventricular end‐systolic diameter >45 mm predicted a higher risk of the primary outcome ( P <0.01). Conclusions Watchful waiting was achieved safely in asymptomatic or equivocally symptomatic chronic severe aortic regurgitation with preserved left ventricular ejection fraction. Preoperative left ventricular end‐systolic diameter >45 mm predicted a poor postoperative outcome and may be an optimal cut‐off value for surgical indication.