Valvular Heart Disease

1356058 - Holodiastolic Flow Reversal and Outcomes in Chronic Aortic Regurgitation: Comparison Against Phase Contrast Quantitative Assessment

Friday, January 27, 2023

10:20 AM – 11:00 AM

Location: Pacific Jewel

Presenting Author(s)

MS

Mujtaba Saeed, MD

Postdoctoral Research Fellow
Houston Methodist DeBakey Heart & Vascular Center, United States

Primary Author(s)

MS

Mujtaba Saeed, MD

Postdoctoral Research Fellow
Houston Methodist DeBakey Heart & Vascular Center, United States

Co-Author(s)

AA

Ahmed I. Ahmed, MD, MPH

Postdoctoral Research Fellow
Houston Methodist DeBakey Heart & Vascular Center, United States
VC

Valentina Crudo, MD

Postdoctoral Research Fellow
Houston Methodist DeBakey Heart & Vascular Center, United States
WZ

William A. Zoghbi, MD

Professor and Chairman, Department of Cardiology
Houston Methodist DeBakey Heart & Vascular Center, Texas, United States
Mouaz Al-Mallah, MD MSc

Professor
Houston Methodist
Dipan J. Shah, MD

Chief, Division of Cardiovascular Imaging
Houston Methodist DeBakey Heart & Vascular Center
Houston, Texas, United States
Maan Malahfji, MD

Assistant Professor of Cardiology, Director of CMR Research
Houston Methodist DeBakey Heart & Vascular Center
Houston, Texas, United States

Disclosure(s):

Dipan J. Shah, MD: No relevant disclosure to display

Background: The presence of holodiastolic flow reversal (HDR) in the descending aorta (DA) suggests hemodynamically significant AR.¹ There are limited studies comparing HDR to traditional phase contrast (PC) quantitation of AR severity, and its association with outcomes in patients with chronic AR.

Methods: We studied patients with ≥moderate AR on PC cardiac magnetic resonance, defined as regurgitant volume (RVol) ≥30 ml or regurgitant fraction (RF) ≥30%. We excluded patients with irregular heart rhythms, prior valvular intervention, >mild concomitant valve disease, primary cardiomyopathy unrelated to AR, aortic dissection, congenital heart disease, and end-stage disease with a competing mortality risk. A blinded assessment for presence of HDR in the DA was performed using routine PC sequences of the ascending aorta. HDR was defined as reversed flow of >10ml/sec in the DA through majority of the diastolic reverse flow.² The primary outcome was aortic valve replacement or repair (AVR) indicated for symptoms or low ejection fraction, or death under medical management.

Results: We studied 347 patients (median age 61 [interquartile range-IQR, 50-70 years]), 79.3% men, and 30.3% with bicuspid valves. Median aortic valve regurgitant fraction was 37% (32%-44%), and 35% of patients had ≥NYHA II symptoms. HDR was present in 169 (48.7%) patients. On ROC analysis, the RVol and RF thresholds associated with HDR were 49 ml and 39% (AUC 0.75 and 0.78). At a median follow up 2.55 (IQR 0.9-4.64) years, 151 patients (43.5%) underwent AVR and there were 25 (12.7%) deaths in the medically managed patients. In multivariable Cox regression analysis adjusting for age, sex, left ventricular ejection fraction, indexed left ventricular systolic volume, and NYHA class, both HDR (HR 1.89 [1.36-2.63]); P< 0.001, C-Statistic 0.71) as well as RF (HR 1.05, [1.03-1.07], C-Statistic 0.74, P< 0.001) were independently associated with the outcome.

Conclusion: Holodiastolic flow reversal in the descending aorta is associated with a need for valve intervention or death, beyond traditional risk factors of AR. Evaluation for HDR on CMR may represent a single, easily obtainable measure for the identification of significant aortic regurgitation.