Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access
Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc
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Original Article

Volume 16, Number 6, December 2025, pages 525-532

Total Regurgitant Fraction to Predict Aortic Valve Surgery in Patients With Concomitant Aortic and Mitral Regurgitation

Figures

↓  Figure 1. Obtention of the mentioned volumes and regurgitant fractions in velocity encoding phase contrast imaging (left) and its schematic representation in left cardiac chambers. ARF: aortic regurgitant fraction; ARV: aortic regurgitant volume, FV: forward volume; LA: left atrium; LVEDV: left ventricular end-diastolic volume; LVESV: left ventricular end-systolic volume; LVSV: left ventricular stroke volume; MRF: mitral regurgitant fraction; MRV: mitral regurgitant volume; TRF: total regurgitant fraction; TRV: total regurgitant volume; VR: venous return.
Figure 1.
↓  Figure 2. ROC curve representing capacity of ARF (blue line) and TRF (red line) to identify patients at risk of developing surgery indications at 1 year (a), 2 years (b), 3 years (c) and at the end of follow-up (d). ARF: aortic regurgitant fraction; TRF: total regurgitant fraction; CI: confidence interval; AUC: area under the curve; ROC: receiver operating characteristic.
Figure 2.
↓  Figure 3. Surgery-indication free survival by ARF (superior panel) and TRF (inferior panel) best cut-offs determined by Youden method in ROC analysis. ARF: aortic regurgitant fraction; TRF: total regurgitant fraction; ROC: receiver operating characteristic.
Figure 3.

Tables

↓  Table 1. Main Clinical Baseline Characteristics
 
All (n = 45)No indication of surgery (n = 35)Surgery indication (n = 10)P value
AF: atrial fibrillation; HBP: high blood pressure; DAA: dilated ascending aorta; DM: diabetes mellitus; DL: dyslipidemia; BMI: body mass index; CKD: chronic kidney disease; BAV: bicuspid aortic valve.
Age (years)61.5 ± 16.762.2 ± 16.359 ± 190.58
Male (%)34 (75.6%)26 (74.3%)8 (80%)0.71
HBP (%)28 (62.2%)22 (62.9%)6 (60%)0.86
DM (%)1 (2.2%)0 (0%)1 (10%)0.22
DL (%)15 (33.3%)10 (28.6%)5 (50%)0.20
BMI (kg/m2)26.7 ± 4.626.9 ± 4.526.3 ± 5.40.72
Smoker (%)5 (11.1%)4 (11.4%)1 (10%)0.89
Former smoker (%)18 (40%)14 (40%)4 (40%)1.0
AF (%)10 (22.2%)7 (20%)3 (30%)0.71
CKD (%)6 (13.3%)4 (11.4%)2 (20%)0.48
BAV (%)21 (46.7%)18 (51.4%)3 (30%)0.23
DAA (%)6 (13.3%)4 (11.4%)2 (20%)0.48

 

↓  Table 2. Comparison Between Patients Without and With Surgery Indication During Follow-Up
 
All (n = 45)No indication of surgery (n = 35)Surgery indication (n = 10)P value
aDAFR was examined in only 29 patients. LVEDV: left ventricular end diastolic volume; LVESV: left ventricular end systolic volume; LVSV: left ventricular stroke volume; FV: forward volume; LVEF: left ventricular ejection fraction; ARV: aortic regurgitant volume; ARF: aortic regurgitant fraction; MRV: mitral regurgitant volume; MRF: mitral regurgitant fraction; TRV: total regurgitant volume; TRF: total regurgitant fraction; RVEF: right ventricular ejection fraction; DAFR: descendent aorta flow reversal.
LVEDV (mL)186.3 ± 55.5183.8 ± 54.2195.1 ± 62.10.57
LVESV (mL)76.6 ± 32.377.7 ± 32.572.8 ± 33.10.67
LVSV (mL)109.7 ± 29.6106.1 ± 27.9122.3 ± 33.30.12
FV (mL)95.5 ± 26.193.4 ± 24.1103.8 ± 32.20.26
LVEF (%)60.0 ± 8.458.9 ± 8.463.9 ± 7.20.09
ARV (mL)23.0 ± 13.220.3 ± 11.832.2 ± 14.60.01
ARF (%)22.9 ± 9.221.0 ± 8.129.5 ± 10.10.01
MRV (mL)14.2 ± 9.312.9 ± 9.618.5 ± 7.40.09
MRF (%)16.4 ± 8.714.9 ± 7.921.6 ± 9.80.029
TRV (mL)37.1 ± 18.633.2 ± 16.850.7 ± 19.00.007
TRF (%)32.8 ± 10.230.4 ± 9.241.2 ± 9.40.002
RVEF (%)61.6 ± 8.061.5 ± 8.261.9 ± 7.70.88
DAFRa (n = 29)14 (48.3%)a6 (28.6%)a8 (100%)a0.001

 

↓  Table 3. ROC Data (Comparison of the Ability of Each Parameter to Identify the Patients Who Develop Indications for Surgery at the End of Follow-Up)
 
AUCCut-offP valueSensitivity (%)Specificity (%)
ARV: aortic regurgitant volume; ARF: aortic regurgitant fraction; MRV: mitral regurgitant volume; MRF: mitral regurgitant fraction; TRV: total regurgitant volume; TRF: total regurgitant fraction; ROC: receiver operating characteristic.
ARV (mL)0.75 (0.54 - 0.96)330.0157091
ARF (%)0.75 (0.56 - 0.94)290.0187085
MRV (mL)0.72 (0.55 - 0.89)150.0389065
MRF (%)0.72 (0.53 - 0.90)180.0418065
TRV (mL)0.77 (0.59 - 0.94)470.0117085
TRF (%)0.79 (0.62 - 0.96)400.0067089

 

↓  Table 4. Cox Proportional Hazard Regression for the Variables With Significant Discriminatory Ability on ROC Analysis
 
Univariate analysisMultivariate analysis
Hazard ratio (B-Exp)P valueHazard ratio (B-Exp)P value
Analysis was binary comparing groups above and below the optimal threshold. Multivariate analysis was adjusted for LVEF. ARV: aortic regurgitant volume; ARF: aortic regurgitant fraction; MRV: mitral regurgitant volume; MRF: mitral regurgitant fraction; TRV: total regurgitant volume; TRF: total regurgitant fraction; ROC: receiver operating characteristic.
ARV (mL)9.77 (2.51 - 38.02)0.0018.10 (1.82 - 36.02)0.006
ARF (%)6.98 (1.77 - 27.44)0.0055.42 (1.29 - 22.72)0.02
MRV (mL)11.46 (1.45 - 90.63)0.029.28 (1.14 - 75.62)0.04
MRF (%)6.66 (1.40 - 31.67)0.025.53 (1.15 - 26.59)0.03
TRV (mL)6.63 (1.71 - 25.69)0.0065.54 (1.40 - 21.90)0.02
TRF (%)12.05 (2.49 - 58.33)0.00211.78 (2.39 - 58.01)0.001