American Society of Echocardiography (ASE) guidelines for echocardiographic evaluation of aortic regurgitation (AR) were found to “display very good performance” in detecting significant AR, according to a study published Nov. 13 in JACC: Cardiovascular Imaging.

Rowa Attar, MBBCH, William A. Zoghbi, MD, MACC, et al., studied 81 patients (median age 52 years, 74% male, 58% with a bicuspid aortic valve) with AR who underwent both echocardiography and cardiac magnetic resonance (CMR) within four hours of each other. AR severity was graded according to ASE guidelines.

Echocardiography identified 43% of patients as having mild AR, 22% moderate AR, 15% moderate to severe AR and 20% as having severe AR. Meanwhile, CMR found that 50.6% of patients had mild AR, 19.8% had moderate AR, 8.6% had moderate to severe AR and 21% had severe AR.

The authors note that “overall concordance of AR severity assessment between [echocardiography] and CMR using the ASE guidelines was moderate (64.2%; kappa 0.48 [95% CI, 0.33-0.62]; p<0.001).” The area under the curve for detection of severe AR by CMR with the current ASE algorithm was 0.9 (82.4% sensitivity and 96.9% specificity).

Echocardiographic parameters most accurate in assessing AR severity were vena contracta width, jet width and left ventricle end-diastolic volume index (area under the curve, 0.86-0.89), while pressure half-time exhibited the lowest accuracy.

An additional study published on Nov. 13 in JACC: Cardiovascular Imaging found that patients with asymptomatic clinically significant chronic AR experienced a survival penalty when current ACC/American Heart Association Class I/IIa guideline recommendations were present. Vidhu Anand, MBBS, FACC, et al., point to three markers of early left ventricular (LV) dysfunction associated with all-cause mortality, suggesting they can help identify patients who may benefit from early surgical intervention.

The authors included 673 patients (mean age 57 years, 14% female) and examined the relationship between the following markers: left ventricular ejection fraction (LVEF)<60%, indexed end-systolic volume (iESV)≥45 mL/m², and global longitudinal strain (GLS) worse than –15%, with the study’s primary endpoint of all-cause mortality. They compared when all Class I/IIa guidelines recommendations were present vs. when any were absent.

Results showed that 48% of patients underwent aortic valve replacement and 10% died while under surveillance. Among patients studied, 44% had LVEF<60%, 39% had iESV≥45 mL/m², and 25% had GLS worse than -15%.

The authors note that “mortality under surveillance was highest when Class I/IIa recommendations were present (hazard ratio [HR], 4.22; 95% CI, 2.15-8.92), followed by the presence of one or more markers of early LV dysfunction (HR, 2.18; 95% CI, 1.21-3.92); no markers were used as the reference (all, p<0.05).” LVEF exhibited the strongest association with all-cause mortality among the markers assessed.

With Class I/IIa recommendations absent, mortality increased with an increasing number of markers present. Highest mortality was associated with all three markers present (HR, 5.46; 95% CI, 2.51-11.90; p<0.001).

“Given the development of better methods to assess LV size (2- and 3-dimensional volumes) and novel indicators of LV dysfunction (GLS), there is an urgent need to prospectively evaluate their association with mortality and determine their role as triggers for surgery,” state the authors.

Clinical Topics: Noninvasive Imaging, Valvular Heart Disease, Echocardiography/Ultrasound

Keywords: Aortic Valve Insufficiency, Ventricular Function, Left, Echocardiography, Magnetic Resonance Spectroscopy