Left ventricular remodeling in chronic aortic regurgitation: both age and sex matter

Abstract Background For chronic and severe aortic regurgitation (AR), both European and American guidelines recommend surgery in the setting of dilated left ventricle (LV). However, normal LV volumes are described according to age and gender (1) and differences in remodeling according to gender have been described in AR (2) and late referral bias has been suggested as a cause for outcome penalty in female patients with AR (3). Objective and methods To clarify the interactions of age and gender on LV volumes in the setting of AR with cardiac magnetic resonance (CMR). This is a single-center study performed in a referral center for cardiac surgery and aortic valve repair. Patients were adults identified or referred for an at least moderate AR (grade II) by transthoracic echocardiogram (TTE) and were invited to perform a CMR. Exclusion criteria were acute AR caused by bacterial infection or dissection, dilated cardiomyopathy from another identified cause, concomitant more than moderate left heart valve disease or intra-cardiac devices. Results Among 296 patients included (51+/-16 years, 56 (19%) females and 129 (44%) bicuspid), mean regurgitant fraction (RF) was 33%. Age was similar among men and women (50+/-16 vs 54+/-16; p=0.142) but RF was higher among men (35+/-18 vs 25+/-15%, p<0.001). Both LV end-diastolic (iLVEDV) and end-systolic (iLVESV) were moderately correlated to regurgitant fraction (Pearson R of respectively 0.605 and 0.569). Women had lower iLVEDV and iLVESV than men after correction for AR severity (respectively 105+/-24 vs 136+/-43ml/m²; p<0.001 and 48+/-17 vs 66+/-30ml/m²; p=0.007). Female gender was associated with a significantly lower susceptibility to dilate both iEDV and iESV in the setting of an increasing AR severity (p for interaction of respectively 0.048 and 0.041). Similarly, advancing age was associated with a continuous decrease in iEDV and iESV dilatation ability (p for interaction of respectively 0.006 and 0.048). Conclusion Sex and age are significant determinants for LV volumes in AR. Furthermore, both female sex and aging independantly lead to a decreased capability of LV dilatation, suggesting sex and aged-based CMR thresholds for LV dilatation should be further developed to avoid possible late referral bias for surgery in female or elderly population.Gender interaction on LV dilatationLV volumes prediction models