Systematic review and meta-analysis of 27 cohort studies (4,720 patients; mean age 49 years; median follow-up 3.9 years) on the natural history of asymptomatic moderate or severe aortic regurgitation (AR). Pooled incidence per 100 person-years: all-cause mortality 1.75 (95% CI 1.27-2.41), cardiac death 1.29, sudden death 0.29, new symptoms 4.30, and aortic valve replacement/repair (AVR) 7.01. Asymptomatic LV dysfunction occurred at only 0.9 per 100 person-years. Mortality rates were more than double those of the general population irrespective of age — 2.45 per 100 person-years in cohorts ≥50 years versus 0.59 in younger cohorts. Early AVR was associated with lower mortality (pooled HR 0.33; 95% CI 0.30-0.37). The findings contradict the historical view of AR as a 'benign' valvular lesion and argue for earlier intervention guided by more sensitive markers of LV damage.
The natural history of asymptomatic moderate or severe aortic regurgitation (AR) remains uncertain, with conflicting reports about its progression and surgical timing. We aimed to quantify adverse outcomes under conservative management and evaluate the association of aortic valve replacement/repair (AVR) with mortality.
Systematic searches (inception–July 2025) identified cohort studies of asymptomatic moderate/severe AR. Random-effects models estimated pooled incidence rates of adverse events; fixed-effects models were used for hazard ratios (HRs) of AVR vs conservative management.
Twenty-seven studies (4720 patients; mean age 49 years; mean follow-up 3.9 years) were included. Pooled incidence rates per 100 person-years were 1.75 (95% CI 1.27 to 2.41) for all-cause mortality, 1.29 for cardiac death, 0.29 for sudden death, 4.30 for new symptoms and 7.01 for AVR. Asymptomatic low left ventricular ejection fraction occurred in only 0.9 per 100 person-years. Mortality rates were more than double those of the general population across age groups—2.45 (1.90 to 3.18) per 100 person-years for cohorts with mean age ≥50 years versus 0.59 (0.29 to 1.21) for younger cohorts. Early AVR was associated with lower mortality (pooled HR 0.33; 95% CI 0.30 to 0.37).
Asymptomatic moderate/severe AR carries significant excess mortality irrespective of age, contradicting its historically benign reputation. Given the rarity of asymptomatic LV dysfunction, earlier intervention guided by more sensitive markers of LV damage may improve outcomes, although heterogeneity and study quality warrant cautious interpretation.
CRD42024522683.
