(VP086) PROGNOSTIC VALUE OF CARDIAC DAMAGE STAGING CLASSIFICATION IN CHRONIC AORTIC REGURGITATION

Background: Current American and European recommendations for the management of chronic aortic regurgitation (AR) are based on AR severity (graded by echocardiography), symptoms and repercussions on the left ventricle (LV). However, these triggers for intervention are known to provide only modest risk stratification value in AR patients. We sought to evaluate the prognostic value of a new staging classification characterizing the extent of cardiac damage in patients with AR.

METHODS AND RESULTS: Three hundred and sixty nine patients with moderate or severe AR between 2014 and 2015 were retrospectively analyzed (66 ± 17 years, 55% men, median [interquartile range] EuroSCORE II 1.6 [0.9-3.4]%). Patients were hierarchically classified in the following staging classification based on a multiparameter approach: stage 0: no cardiac damage; stage 1: LV damage defined as LV end-systolic diameter >45mm or ≥20mm/m2, LV systolic dysfunction (LV ejection fraction < 55%) or LV diastolic dysfunction grade ≥2; stage 2: left atrial (LA), ascending aorta or mitral valve damage defined as an indexed LA volume >40ml/m2, atrial fibrillation, ≥moderate mitral regurgitation or ascending aorta diameter ≥45mm or 21mm/m2; stage 3: pulmonary vasculature or tricuspid valve damage defined as systolic pulmonary artery pressure ≥60mmHg or ≥moderate tricuspid regurgitation; and stage 4: ≥moderate right ventricular dysfunction defined as tricuspid annulus plane systolic excursion < 17mm or s’ wave < 9.5cm/s.

Among the 369 patients, 47 (13%) patients were in stage 0, 62 (17%) in stage 1, 154 (42%) in stage 2, 27 (7%) in stage 3 and 79 (21%) in stage 4. Cox-adjusted curves demonstrated a stepwise increase of mortality (76 events, 21%) and the composite endpoint of all-cause mortality and cardiovascular hospitalization (109 events, 30%) between each stage (Figure). Comprehensive multivariate analyses adjusted for EuroSCORE II, hypertension, bicuspid aortic valve, AR etiology and severity, and aortic valve replacement as a time-dependent variable showed that the staging classification was independently associated with an increased risk of all-cause mortality (hazard ratio [95% confidence interval (CI)]: 1.51 [1.25-1.83] per one-stage increase, p< 0.001) and with the composite (1.31 [1.12-1.52] per one-stage increase, p< 0.001; Table). In stages ≥2, patients were respectively at a 2.7- and 2.1-fold increased risk of events in multivariate analyses (all p≤0.007); Table).

Conclusion: The new cardiac damage staging classification proposed in this study provides powerful and independent prognostic value in patients with AR and may thus be useful to enhance risk stratification and eventually trigger intervention in these patients.