Left ventricular dilatation serves as a cornerstone prognostic marker in chronic aortic regurgitation, prompting surgical intervention per guideline thresholds despite limited sex-specific validation. Current recommendations apply uniform LV end-systolic diameter index (LVESDi) cutoffs alongside recently adopted LV end-systolic volume index (LVESVi) thresholds of 45 mL/m² irrespective of sex. 
This multicenter cohort study published in the JAMA Cardiology spanning five international centers from 2003 to 2022 enrolled 808 asymptomatic patients with moderate-severe aortic regurgitation and preserved ejection fraction (≥50%), excluding those with significant comorbidities or prior valve surgery. 
Investigators meticulously quantified linear (LVESDi) and volumetric (LVESVi) remodeling parameters, correlating these with all-cause mortality during conservative management and post-aortic valve surgery over median 7-year follow-up through comprehensive multivariable modeling and receiver operating characteristic analyses.
Baseline Remodeling Patterns Differ by Sex
Among 488 men and 320 women averaging 56 years, baseline LVESDi proved comparable between sexes at 20 mm/m² (P=0.77), while men exhibited significantly larger LVESVi (39 versus 31 mL/m², P<0.001), highlighting volumetric sex disparities despite equivalent linear dilatation.
Medical Management Reveals Sex-Modified Risk
During conservative follow-up, 74 deaths occurred, with women demonstrating inferior 6-year survival (80% versus 89%, P=0.001). Receiver operating characteristic analysis established LVESDi ≥20 mm/m² as the optimal mortality threshold across both sexes. LVESVi cutoffs diverged by sex: ≥40 mL/m² for women and ≥45 mL/m² for men, validated through age-adjusted cubic splines maintaining significance following multivariable adjustment. LVESVi demonstrated sex interaction for prognostic utility absent with LVESDi.
Surgical Outcomes Favor Volumetric Assessment
Among 323 surgically managed patients, sex-specific survival equalized post-aortic valve surgery (85% women versus 89% men, P=0.31). Preoperative LVESVi independently predicted mortality with significant sex interaction (HR 1.03, 95% CI 1.00-1.06, P=0.04), underscoring superior risk stratification over linear metrics.
Refine AR Surveillance With Tailored Metrics
Cardiologists and cardiac surgeons gain evidence supporting LVESDi ≥20 mm/m² as a unisex intervention trigger below current guidelines, alongside sex-specific LVESVi thresholds optimizing timing. Volumetric assessment captures remodeling nuances particularly relevant for women, enhancing shared decision-making in asymptomatic moderate-severe aortic regurgitation.