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Chronic Aortic Insufficiency: Factors Associated with Progression to Aortic Valve Replacement

Deirdre Siemienczuk, RN; Barry Greenberg, MD; Cynthia Morris, PhD; Barry Massie, MD; Richard A. Wilson, MD; Nina Topic, RN; J. David Bristow, MD; and Melvin Cheitlin, MD
[+] Article, Author, and Disclosure Information

Grant Support: Partial support by grants from the National Heart, Lung, and Blood Institute (HL-28146), the Medical Research Foundation of Oregon, and the Veterans Administration.

Requests for Reprints: Barry Greenberg, MD, Division of Cardiology—L462, Oregon Health Sciences University, 3181 S. W. Sam Jackson Park Road, Portland, OR 97201.

Current Author Addresses: Ms. Siemienczuk, Drs. Greenberg, Wilson, Morris, and Bristow: Division of Cardiology, Oregon Health Sciences University, Portland, OR 97201.

Dr. Massie and Ms. Topic: Veterans Administration Medical Center, San Francisco, CA 94121.

Dr. Cheitlin: San Francisco General Hospital, Cardiology Rm 5G-1, San Francisco, CA 94110.

Ann Intern Med. 1989;110(8):587-592. doi:10.7326/0003-4819-110-8-587
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Study Objective: To determine whether the initial measurement of clinical variables in patients with chronic stable aortic insufficiency is helpful in identifying patients at risk for earlier progression to aortic valve replacement.

Design: Prospective analysis of a cohort of patients for a median follow-up time of 44 months (range, 8 to 57).

Setting: Referral-based cardiology clinics at two university hospitals and their affiliated Veterans Administration medical centers.

Patients: Cohort of 50 asymptomatic or minimally symptomatic patients with chronic aortic insufficiency and left ventricular enlargement. Patients had preserved left ventricular ejection fraction at rest and no evidence of coronary artery disease or significant noncardiac illness.

Intervention: None.

Measurements and Main Results: Baseline evaluation included a history and physical examination, chest roentgenogram, M-mode echocardiogram, treadmill test, and radionuclide angiogram done at rest and during supine bicycle exercise. Ten patients progressed to surgery because of the onset of limiting symptoms or objective evidence of left ventricular dysfunction, or both; the overall rate was 4% ± 3% per year. The Breslow and Mantel-Cox statistics were used to compute survival (surgery-free) dichotomized by prognostic variables. The progression to surgery was earlier in patients with left ventricular end-diastolic volume indices of 150 cc/m2 or more, end-systolic volume indices of 60 cc/m2 or more, a left ventricular ejection fraction at maximal exercise of less than 0.50, or an end-systolic wall stress of 860 dynes/cm2 or more.

Conclusions: Patients at higher and lower risk for early progression to aortic valve replacement can be identified through the measurement of left ventricular size and function. This information can be used to decide the frequency and intensity of follow-up evaluation in these patients.





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