Objective: The clinical outcome of asymptomatic patients with aortic regurgitation (AR) remains uncertain and the impact on outcome of AR quantitative classification recommended by echographic societies is unknown.

Methods: we prospectively enrolled 251 asymptomatic patients (age 60 ± 17 years, 67% male) with AR, quantified AR and left ventricular volumes by Doppler-Echocardiography, and analyzed their outcome.

Results: According to guideline categories, AR was mild if regurgitant volume (RVol) < 30 and effective regurgitant orifice (ERO) < 10, moderate if RVol 30-59 or ERO 10-29 and large if RVol > = 60mL/beat or ERO > = 30 mm². 10-year mortality and cardiac events (cardiac death, atrial fibrillation, heart failure) rates under conservative management were 21 ± 4 and 45 ± 6 and considerably differed between categories (figure). Adjusting for age, sex, comorbidity and ejection fraction, large versus mild AR range remained independently predictive of survival (RR 8 [1.9-56], p = 0.003) and cardiac events (RR 5 [1.7- 18.3], p = 0.02). Jet size and qualitative grading were univariate predictors of outcome (p < 0.03) but were superseded by RVol and ERO in multivariate models. End-systolic volume index (ESVI) was not predictive of death but was independently predictive of cardiac events (p = 0.02) with a RR of 2.8 [1.5-5.1] for ESVI 45ml/m² (p < 0.002).

Conclusion: prospective quantitative graduation of AR is a powerful predictor of clinical outcome and supersedes qualitative grading. Patients with largest AR degree incurred excess mortality and high cardiac events rates. Thus, quantification of AR combined with ESVI identifies high risk patients who require careful clinical attention.