Long-term outcomes and determinants of progression in moderate aortic regurgitation with and without concomitant valvular heart disease

Background Moderate aortic regurgitation (AR) is common, but data on its natural history and progression, especially when associated with concomitant moderate valvular heart disease (VHD), are limited, and its long-term prognostic impact remains unclear. Purpose To compare the natural history of isolated moderate AR with that of moderate AR + another concomitant moderate VHD and to identify clinical and echocardiographic determinants of AR progression. Methods We retrospectively analysed 581 patients, including 178 with isolated moderate AR and 403 with AR + VHD, with a median follow-up of 54.3 months (IQR 30.9–81.6). Patients with one or more subsequent follow-up echocardiograms with quantitative assessment were included. Exclusion criteria considered cardiomyopathy, prior cardiac surgery, LVEF <50%, or severe VHD. VHD severity was graded according to current guidelines. The composite endpoint was all-cause mortality and heart failure hospitalization (HHF). AR progression, time to progression, and echocardiographic parameters of cardiac remodeling and function were assessed. Results Univariate Cox regression analyses were performed to identify predictors of AR progression. Among baseline echocardiographic parameters, aortic root diameter, left ventricular end-systolic volume, and left atrial reservoir strain (LARS) emerged as significant determinants of AR progression.(Table 1) Most patients showed no AR progression during follow-up (approximately 74% in both groups). However, AR progression occurred more frequently in patients with isolated moderate AR compared with those with concomitant AR+VHD (3.3 vs 0.6 per 100 person-years, p < 0.001).(Graphic 1 and Table 2) No significant differences were observed in time to progression between the two groups (mean 29 vs 27 months). A separate multivariable Cox regression analysis was then performed to evaluate the prognostic impact of disease progression on the composite endpoint (all-cause mortality and HHF) in patients with AR+VHD. In this model, disease progression was not independently associated with worse outcomes (HR 1.09, 95% CI 0.49–2.41; p = 0.84). Conclusions Isolated moderate AR is associated with a higher rate of progression compared with patients with AR+VHD, although time to progression does not differ between groups. In patients with AR+ VHD, adverse outcomes are driven by the overall disease burden rather than by AR progression itself, as worsening severity does not independently impact prognosis. Echocardiographic markers likely reflect early myocardial impairment rather than advanced disease progression, supporting their potential role in early risk stratification and tailored follow-up strategies