What is the guideline management of severe aortic regurgitation?

Management of Severe Aortic Regurgitation

Surgery is indicated for all symptomatic patients with severe aortic regurgitation (AR) regardless of left ventricular (LV) function, and for asymptomatic patients with LV dysfunction (LVEF <50-55%) or significant LV dilation. 1, 2

Diagnostic Criteria for Severe AR

Severe AR is characterized by:

• Vena contracta >0.6 cm
• Holodiastolic flow reversal in the descending aorta
• Regurgitant volume ≥60 mL/beat
• Effective regurgitant orifice area (EROA) ≥0.3 cm²
• Evidence of LV dilation
• Doppler jet width ≥65% of left ventricular outflow tract (LVOT)
• Regurgitant fraction ≥50%
• Pressure half-time of regurgitant jet <200 m/s 1

Management Algorithm

1. Symptomatic Severe AR

• Surgical intervention is indicated regardless of LV systolic function (Class IB recommendation) 1, 2
• Surgery should not be delayed, especially with hypotension, pulmonary edema, or evidence of low flow 1
• Intra-aortic balloon counterpulsation is contraindicated in severe AR 1

2. Asymptomatic Severe AR with LV Dysfunction

• AVR is indicated if LVEF <50% (ACC/AHA) or <55% (ESC) when no other cause for LV dysfunction exists (Class IB recommendation) 1, 2
• Recent evidence suggests that patients with LVEF between 50-55% have poorer long-term outcomes after AVR compared to those with LVEF ≥55% 3

3. Asymptomatic Severe AR with Preserved LV Function but Significant LV Dilation

• AVR is reasonable when:
  • LVESD >50 mm (Class IB) or >45 mm (Class IIaB) 1
  • Progressive increase in LV dilation into severe range (LVEDD >65 mm) (Class IIbB-NR) 1
  • Recent data suggests LVEDD ≥81 mm is associated with poorer prognosis after AVR 3

4. Severe AR with Aortic Root Disease

• If surgery is indicated for severe AR, replacement of aortic sinuses/ascending aorta is reasonable when aortic dimension is ≥45 mm (Class IIaB-NR) 1, 2
• In patients with bicuspid aortic valve (BAV), valve-sparing surgery may be considered at comprehensive valve centers 1

5. Severe AR with Concurrent Cardiac Surgery

• AVR is indicated for patients with severe AR undergoing CABG, surgery of ascending aorta, or other valve surgery (Class IC) 1
• AVR is reasonable for moderate AR (stage B) in patients undergoing cardiac surgery for other indications (Class IIaC-EO) 1

Medical Therapy

• For asymptomatic patients with chronic AR and hypertension (systolic BP >140 mmHg), antihypertensive treatment is recommended (Class IB-NR) 1
• For patients with symptoms and/or LV dysfunction but prohibitive surgical risk, guideline-directed medical therapy (GDMT) with ACE inhibitors, ARBs, and/or sacubitril/valsartan is recommended (Class IB-NR) 1
• Medical therapy (ACE inhibitors or dihydropyridines) may provide symptomatic improvement in patients with severe AR when surgery is not feasible 1
• The goal of vasodilator therapy is to achieve a significant decrease in systolic arterial pressure 4

Surveillance and Follow-up

• Severe asymptomatic AR: Every 6-12 months 1
• If significant fall in LVEF or increase in LV size is observed: Every 3-6 months 1
• Moderate AR: Every 1-2 years 1
• Mild AR: Every 3-5 years 1

Special Considerations

Acute Severe AR

• Medical therapy to reduce LV afterload may be given for stabilization, but surgery should not be delayed 1
• This is a surgical emergency due to risk of severe pulmonary edema and hypotension 4

Severe AR with Very Low LVEF (<35%)

• Recent evidence suggests that AVR is still associated with improved survival compared to medical management alone, even in patients with LVEF <35% 5, 6
• After multivariate adjustment, AVR was associated with lower mortality (HR=0.143) compared to medical management 5
• Significant reverse remodeling of the left ventricle and improvement in EF can occur after surgery 6

Mixed Valve Disease

• When both stenosis and regurgitation are present, intervention should follow recommendations for the predominant lesion 2
• For combined AS and AR with peak velocity ≥4.0 m/s and LVEF <50%, AVR is recommended 1

Surgical Options

• Surgical AVR (mechanical or bioprosthetic valve) is the standard intervention 1
• Aortic valve repair may be considered in selected patients with favorable valve anatomy at experienced centers 1
• Transcatheter aortic valve implantation (TAVI) should not be performed in patients with isolated severe AR who are surgical candidates (Class IIIB-NR) 1
• TAVI may be considered in experienced centers for selected patients ineligible for surgical AVR 1

By following this evidence-based approach to severe AR management, clinicians can optimize patient outcomes by intervening at the appropriate time to prevent irreversible LV dysfunction and improve mortality and morbidity.