What is the treatment for severe aortic regurgitation?

Treatment for Severe Aortic Regurgitation

Surgical aortic valve replacement (SAVR) is the definitive treatment for severe aortic regurgitation and is indicated in all symptomatic patients regardless of left ventricular function. 1, 2

Indications for Surgical Intervention

Symptomatic Patients

• Class I recommendation: All patients with symptomatic severe AR should undergo surgical intervention regardless of LV function 1
• Symptoms indicating need for surgery:
  • Dyspnea
  • Exercise intolerance
  • Angina
  • Heart failure symptoms

Asymptomatic Patients

Surgery is indicated in asymptomatic patients with severe AR when:

1. Left ventricular dysfunction is present:

   • LVEF ≤50-55% 1, 2
   • No other cause for LV dysfunction is identified

2. Significant LV dilatation exists:

   • LVESD >50 mm or >25 mm/m² BSA 1, 2
   • LVEDD >70 mm 1
   • Progressive increase in LV dimensions into severe range 1

3. Evidence of progressive LV deterioration:

   • Progressive decline in LVEF on serial studies 1
   • Progressive increase in LV dilatation 1

Timing of Surgery

Early intervention is critical as postoperative outcomes are directly related to:

• Preoperative LV function (LVEF <55% associated with worse outcomes) 3
• Degree of LV dilatation (LVEDD ≥81 mm associated with poorer survival) 3

Management of Acute Severe AR

Acute severe AR represents a surgical emergency requiring:

• Immediate surgical intervention 2
• Temporary medical stabilization with afterload reduction while preparing for surgery 2
• Caution: Intra-aortic balloon counterpulsation is contraindicated 2

Concurrent Cardiac Surgery

Patients with severe AR undergoing other cardiac procedures should have the aortic valve addressed during the same operation:

• Coronary artery bypass grafting (CABG) 1
• Surgery of the ascending aorta 1
• Other valve surgeries 1

Medical Therapy

Medical therapy has a limited role and should not delay surgical intervention:

• For patients not suitable for surgery:
  • ACE inhibitors or dihydropyridine calcium channel blockers for symptomatic improvement 2
  • Optimal guideline-directed medical therapy for heart failure 1
• For hypertension management in patients with AR:
  • Target systolic BP <140 mmHg 2

Surgical Options

1. Surgical aortic valve replacement (SAVR) - gold standard treatment 1, 2

   • Mechanical or bioprosthetic valve options

2. Valve repair - may be considered in:

   • Selected patients with favorable valve anatomy 1
   • Patients with aortic root disease 1
   • Experienced centers only 1

3. Transcatheter aortic valve implantation (TAVI):

   • May be considered in selected high-risk patients ineligible for SAVR 1
   • Not recommended for isolated severe AR in surgical candidates 1

Follow-up and Monitoring

For asymptomatic patients with severe AR not meeting surgical criteria:

• Clinical and echocardiographic evaluation every 6-12 months 1, 2
• More frequent monitoring (3-6 months) if changes in LVEF or LV size are observed 1, 2
• Monitor for:
  • Development of symptoms
  • Changes in LV size and function
  • Aortic dimensions if root pathology is present

Special Considerations

• Mixed valve disease: When AR coexists with aortic stenosis, careful assessment is needed to identify the predominant pathology 1, 2
• Aortic root disease: Specific thresholds for intervention based on aortic dimensions and risk factors 1
• Non-cardiac surgery: Can be performed safely in asymptomatic patients with preserved LV function 1

Prognosis

Without intervention, symptomatic severe AR has:

• Annual mortality rate of up to 25% once symptoms develop 4
• High risk of irreversible myocardial damage if surgery is delayed 5

With timely surgical intervention, outcomes are generally excellent, with 5-year survival rates >90% when surgery is performed before significant LV dysfunction develops 3.