The confounding role of comorbidities in symptom-based decision-making in aortic regurgitation

Backgrounds Aortic regurgitation (AR) is a progressive valvular disorder whose prevalence increases with age. Current guidelines recommend prompt surgical intervention upon symptom onset per se, irrespective of additional markers of disease severity. Purpose Our study aims to identify cardiac and noncardiac determinants of symptoms in patients with severe AR undergoing aortic valve replacement (AVR). Methods This retrospective study included 101 patients who underwent AVR for isolated severe AR at our Institution between 2015 and 2021. Exclusion criteria included aortic dissection, endocarditis, congenital heart disease, severe concomitant valvular disease, or concurrent coronary artery bypass grafting. Clinical and echocardiographic characteristics were compared between asymptomatic and symptomatic patients. Results At preoperative evaluation, one-third of patients were symptomatic. Symptomatic patients were older (68 ± 11 years) and more frequently affected by coronary artery disease (CAD) (p = 0.01) and moderate mitral regurgitation (MR) (p = 0.01). A Charlson Comorbidity Index (CCI) ≥3 showed a strong association with symptom presence (p < 0.001). In multivariate analysis, moderate MR, CAD, and CCI ≥3 emerged as independent predictors of symptoms. A model adjusted for CCI demonstrated improved predictive accuracy (AUC 0.82 vs. 0.73). Conclusions Symptoms in severe AR result from both valvular overload and comorbidities. Current criteria may not fully capture disease severity in elderly. A high comorbid burden strongly influences symptom perception and complicates risk stratification. Incorporating multimorbidity assessments into clinical decision-making may refine patient selection and optimize surgical outcomes.