What are the indications for valve replacement in aortic regurgitation (AR)?

Indications for Valve Replacement in Aortic Regurgitation

Aortic valve replacement (AVR) is indicated for all symptomatic patients with severe AR regardless of left ventricular systolic function, and for asymptomatic patients with severe AR and LV systolic dysfunction (LVEF ≤55%) or severe LV dilation. 1

Class I Indications (Strong Recommendation)

1. Symptomatic patients with severe AR

   • All patients with NYHA class II-IV symptoms (dyspnea, angina, syncope) 1
   • Regardless of LV systolic function 1

2. Asymptomatic patients with severe AR and LV dysfunction

   • LVEF ≤55% (when no other cause for systolic dysfunction is identified) 1
   • LVEF ≤50% according to older guidelines 1

3. Patients with severe AR undergoing other cardiac surgery

   • During CABG, surgery on the aorta, or other heart valve surgery 1

Class IIa Indications (Reasonable to Perform)

1. Asymptomatic patients with severe AR, normal LVEF (>55%), but severe LV dilation

   • LVESD >50 mm or indexed LVESD >25 mm/m² 1
   • End-diastolic dimension >75 mm 1

2. Patients with moderate AR undergoing other cardiac surgery

   • During CABG or surgery on the ascending aorta 1

Class IIb Indications (May Be Considered)

1. Asymptomatic patients with severe AR and normal LVEF (>55%) with:
   • Progressive decline in LVEF to the low-normal range (55-60%) on serial studies 1
   • Progressive LV dilation (LVEDD >65 mm) 1
   • LVEDD >70 mm or LVESD >50 mm 1
   • Evidence of declining exercise tolerance 1
   • Abnormal hemodynamic responses to exercise 1

Important Considerations

Prognostic Factors

• Patients with LVEF <55% or LVEDD ≥81 mm have poorer long-term survival after AVR 2
• Mortality benefit has been demonstrated with AVR even in patients with severe LV dysfunction (EF ≤35%) 3
• Early surgical intervention before development of severe LV dysfunction improves outcomes 4

Monitoring Recommendations

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

Surgical Options

• Surgical AVR remains the standard intervention for AR 5
• Valve repair may be considered in selected patients with favorable anatomy at experienced centers 5
• Transcatheter AVR is not recommended for isolated severe AR in surgical candidates 1, though emerging data shows promise in high-risk patients with LV dysfunction 6

Common Pitfalls to Avoid

1. Delaying surgery until symptoms develop - By the time symptoms appear, irreversible LV damage may have occurred
2. Overlooking LV dilation - Progressive LV dilation is an important indicator for surgery even with preserved LVEF
3. Failing to adjust thresholds for patient size - Lower threshold values should be considered for patients of small stature 1
4. Missing concomitant aortic root disease - Patients with aortic root disease may require earlier intervention

Algorithm for Decision-Making in AR

1. Assess AR severity (severe = vena contracta >0.6 cm, holodiastolic flow reversal, regurgitant volume ≥60 mL)
2. Evaluate symptoms (if present → AVR indicated)
3. If asymptomatic, assess LV function:
   • LVEF ≤55% → AVR indicated
   • LVEF >55% → Assess LV dimensions:
     • LVESD >50 mm or indexed LVESD >25 mm/m² → AVR reasonable
     • LVEDD >70 mm → AVR may be considered
     • Serial decline in LVEF to 55-60% → AVR may be considered
4. Consider surgical risk and comorbidities when making final decision

The decision for valve replacement should be made before irreversible LV damage occurs, as this significantly impacts postoperative outcomes and long-term survival.