The Surge

For many patients with severe symptomatic aortic regurgitation (ssAR), surgical aortic valve replacement (SAVR) is a primary treatment option. However, despite the class I indication for SAVR, most patients with ssAR do not receive SAVR treatment within one year: a study found that only 26% of ssAR patients were treated with SAVR within one year of diagnosis.

The impact of SAVR treatment may have a dramatic effect on clinical outcomes—in the study, patients who did not undergo surgery had a 2.7-fold increased risk of mortality through 1 year compared to those who received SAVR (P<0.0001).

The lead author of the study, Dr. Vinod H. Thourani, was motivated by what he sees as a lack of data on AR up to this point. “With AR, there are guidelines for treatment, but there haven’t been a ton of studies,” he said, “which is why these study results are so compelling. This is one of the first papers to show that patients with AR don’t do very well when left alone.”

In the year following an ssAR diagnosis, SAVR saves lives

The study used a United States dataset of de-identified electronic health records to include patients with newly diagnosed ssAR between 2008 and 2016.

In this analysis, 4,608 ssAR patients were evaluated and 1,185 (25.7%) received SAVR within 1 year of diagnosis.

Patients who underwent SAVR had a 62% reduction in risk of 1-year mortality compared to patients who did not undergo surgery.

The crucial role of the primary cardiologist

Importantly, the study included details on the primary cardiologists for each ssAR patient. Primary cardiologists were ranked based on the likelihood of their ssAR patients being treated with SAVR within 1 year of ssAR diagnosis.

This revealed a major insight: the receipt of SAVR was found to be strongly influenced by the patient’s primary cardiologist. Patients who were managed by cardiologists with the lowest SAVR treatment rate were treated for ssAR at a significantly lower rate than would be expected given their risk characteristics.

According to Dr. Thourani, the relationship between the cardiologist and the patient is essential. “For one thing, patients are not eager to have open-heart surgery. Depending on how the choice is described to them by their cardiologist, they may delay or even decline SAVR entirely.”

A source of delay in getting ssAR patients SAVR treatment may also be the patients’ perceptions and self-reporting of symptoms. Dr. Thourani went on to say, “The first challenge is that AR is what we call an indolent disease—it may not show symptoms for a while, perhaps years. In addition, patients may unknowingly downplay their symptoms.”

The quiet, slow-progressing symptoms of ssAR may lead patients and their cardiologists to feel less urgency in treating the condition. Additional factors found in the study were patient gender and age: women and patients >80 years old were significantly less likely to be treated with SAVR.

“We tend to see that women present with ssAR later in life and are less symptomatic—or they perceive themselves to be less symptomatic. And, unfortunately, many of their cardiologists aren’t recommending them for surgery if they aren’t experiencing noticeable symptoms.”

Look to the Heart Team to lead the way

With ssAR, there could be difference of perspective between the cardiologist and the surgeon. While the cardiologist may feel less urgency to treat ssAR with SAVR within the first year of diagnosis, surgeons tend to see ssAR as a condition to be addressed without delay.

However, the indolent nature of ssAR remains a key challenge. Unlike aortic stenosis, a similar condition, ssAR may be difficult to diagnose at first. An evaluation of ssAR may be more nuanced, depending on the quality of the echocardiogram and the experience of the technician.

As a result of the study's findings, the authors propose improving education around the diagnosis of ssAR with echocardiography as a major goal for improving mortality rates.

In a larger sense, addressing the gaps in quality care delivered to ssAR patients will require a renewed sense of urgency around the condition.

For this, Dr. Thourani recommends looking to surgeons in the field. “What we, and cardiologists especially, can take away from this study is that we should consider sending patients to a heart team at the first sign of severe AR, whether symptomatic or not symptomatic.”

To learn more about Aortic Regurgitation, read the clinical summary of the publication by Dr. Vinod H Thourani and his team
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