What is the assessment and plan for aortic insufficiency?

Assessment and Plan for Aortic Insufficiency

The assessment and plan for aortic insufficiency should focus on determining severity, etiology, hemodynamic impact, and appropriate timing for intervention based on echocardiographic findings, symptoms, and left ventricular dimensions.

Assessment Components

1. Severity Classification

• Quantitative Parameters:
  • Regurgitant volume and fraction
  • Effective regurgitant orifice area
  • Vena contracta width
  • Pressure half-time
  • Diastolic flow reversal in descending aorta

2. Etiology Assessment

• Type I dysfunction: Aortic root dilatation/annular enlargement 1
• Type II dysfunction: Cusp prolapse 2
• Type III dysfunction: Restrictive leaflet motion (fibrosis/calcification) 2

3. Left Ventricular Assessment

• Critical measurements:
  • LV end-systolic dimension (LVESD) - critical threshold ≥55 mm 3
  • LV end-diastolic dimension (LVEDD)
  • LV ejection fraction (LVEF)
  • LV mass and relative wall thickness 1
  • Global longitudinal strain if available

4. Associated Findings

• Presence of bicuspid aortic valve
• Aortic root/ascending aorta dimensions 1
• Concomitant aortic stenosis 1
• Secondary mitral regurgitation 1

Management Plan

1. Asymptomatic Patients with Chronic AI

• Mild to moderate AI:

  • Echocardiographic follow-up every 1-2 years
  • Blood pressure control (avoid beta-blockers if isolated AI)
  • Endocarditis prophylaxis per current guidelines

• Severe AI without LV dysfunction:

  • Echocardiographic follow-up every 6-12 months 1
  • Exercise testing to unmask symptoms
  • Consider surgery when LVESD approaches 50 mm or LVEF declines

2. Symptomatic Patients

• Severe AI with symptoms:
  • Prompt referral for aortic valve intervention
  • Pre-operative cardiac catheterization to assess coronary arteries
  • Optimization of heart failure symptoms before surgery

3. Surgical Planning

• Valve repair considerations:

  • Type I: Root remodeling or replacement 2
  • Type II: Leaflet resuspension or plication 2
  • Type III: Limited options for repair; replacement often needed 2

• Valve replacement options:

  • Mechanical valve (younger patients, already on anticoagulation)
  • Bioprosthetic valve (older patients, contraindication to anticoagulation)
  • Valve-sparing root replacement if appropriate

4. Special Scenarios

• AI with aortic aneurysm:

  • Consider intervention when ascending aorta ≥5.5 cm (or lower threshold with risk factors) 1
  • More aggressive threshold (4.5 cm) for bicuspid valves or genetic syndromes 1

• AI with LV assist device:

  • Monitor for progressive AI which occurs in up to 38% by 3 years 4
  • Consider AV repair at time of LVAD implantation if moderate AI present 1

Follow-up Protocol

• Mild AI: Echo every 3-5 years
• Moderate AI: Echo every 1-2 years
• Severe AI, normal LV function: Echo every 6-12 months 1
• Severe AI, borderline LV function: Echo every 3-6 months
• Post-repair/replacement: Baseline echo, then at 6-12 months, then annually if stable

Indications for Intervention

1. Symptomatic severe AI
2. Asymptomatic severe AI with LVEF <50%
3. Asymptomatic severe AI with LVESD ≥50 mm (or ≥25 mm/m² BSA)
4. Severe AI undergoing cardiac surgery for other indications
5. Severe AI with progressive LV dilation on serial imaging

Remember to document all echocardiographic parameters, symptoms, functional capacity, and rationale for management decisions in the assessment and plan.