Increased left atrial pressure in chronic aortic regurgitation: association with outcomes

Background In patients with moderate-severe and severe chronic AR, aortic valve surgery (AVS) is recommended after symptom onset, development of left ventricular (LV) dilatation or LV systolic dysfunction. However, risk stratification of asymptomatic patients with preserved LV ejection fraction (LVEF) remains challenging and there is limited data regarding the impact of elevated left atrial pressure (LAP) in this population. Purpose To evaluate the association between elevated LAP and long-term outcomes in asymptomatic patients with moderate-severe or severe chronic AR and preserved LVEF (≥50%) in a multicenter setting. Methods A total of 795 asymptomatic patients (mean age 55±19 years, 61% male) with at least moderate-severe chronic AR and LVEF ≥50% were included. LAP was assessed according to the 2025 ASE/EACVI echocardiographic recommendations. Elevated LAP was defined as the presence of at least 3 of the following criteria: average e′ velocity <6.5 cm/s, E/e′ ratio >14, left atrial volume index (LAVI) >34 mL/m², left atrial reservoir strain (LARS) ≤18%, and tricuspid regurgitation (TR) velocity >2.8 m/s or pulmonary artery systolic pressure (PSAP) ≥35 mm Hg. Exclusion criteria included acute AR, atrial fibrillation at the time of echocardiography, more than mild concomitant mitral regurgitation, mitral stenosis, aortic stenosis, or insufficient data to assess LAP (≥2 missing parameters). The study endpoint was all-cause mortality, with AVS during follow-up accounted as a time-dependent covariate. Results During a median follow-up of 7.0 years (IQR, 2.4–11.6 years), 119 patients (15%) died and 315 (40%) underwent AVS. Patients were categorized as having normal LAP (n = 586, 74%) or elevated LAP (n = 196, 26%). Patients with elevated LAP were older, more frequently female, and had a higher prevalence of arterial hypertension but a lower prevalence of bicuspid aortic valve (BAV) (Table 1). Despite smaller indexed LV linear and volumetric dimensions and less severe AR, patients with elevated LAP experienced higher mortality (Figure 1A). After multivariable adjustment for age, sex, coronary artery disease, AH, diabetes, BAV, AR severity, LV end-systolic volume index, tricuspid annular plane systolic excursion < 17 mm, ascending aorta diameter index, and AVS (as a time-dependent covariate), elevated LAP remained independently associated with all-cause mortality (HR 2.085, 95%CI 1.357-3.201, p<0.001). Adjusted 10-year survival was significantly lower in patients with elevated LAP (63% vs. 80%, p<0.001), corresponding to an approximately 2-fold higher risk of death (Figure 1B). Conclusion Among asymptomatic patients with moderate-severe or severe chronic AR and preserved LVEF, elevated LAP is independently associated with increased long-term mortality, suggesting that markers of elevated LV filling pressures may improve risk stratification of these patients.