What is the treatment for aortic regurgitation?

Treatment of Aortic Regurgitation

For patients with chronic aortic regurgitation, treatment should focus on vasodilator therapy with agents that do not slow the heart rate (avoiding beta blockers), along with careful monitoring and timely surgical intervention when indicated. 1, 2

Medical Management

Vasodilator Therapy

• First-line agents for hypertensive patients with AR:
  • ACE inhibitors
  • Dihydropyridine calcium channel blockers (e.g., amlodipine)
  • These agents reduce LV volume and mass and improve LV performance 2
  • Avoid beta blockers in chronic AR as they may increase diastolic filling period due to bradycardia, potentially worsening aortic insufficiency 1

Blood Pressure Management

• Target systolic hypertension while maintaining adequate diastolic pressure
• Start at low doses and gradually titrate upward as needed 1
• Caution: Marked reduction in diastolic BP may lower coronary perfusion pressure in severe AR 1

Monitoring Protocol

Frequency of Evaluation

• Severe AR: Every 6-12 months
• Moderate AR: Every 1-2 years
• Mild AR: Every 3-5 years
• More frequent monitoring (every 3-6 months) if deterioration in LV function or increase in LV size 2

Key Parameters to Monitor

• Symptoms (dyspnea, angina, syncope)
• LV dimensions (LVEDD, LVESD)
• LV ejection fraction
• Exercise tolerance

Surgical Intervention

Indications for Surgery

1. Symptomatic patients with severe AR (Class I indication)
2. Asymptomatic patients with severe AR and:
   • LV ejection fraction <50-55%
   • LV end-systolic diameter >50 mm or >25 mm/m²
   • LV end-diastolic diameter >65 mm
   • Progressive decline in LVEF 2

Surgical Options

• Aortic valve replacement (primary intervention)
• Valve-sparing operations in selected cases
• Transcatheter aortic valve replacement (TAVR) for high surgical risk patients 2

Special Considerations

Acute AR

• Surgical emergency requiring immediate intervention
• Presents with severe pulmonary edema and hypotension 3

Marfan Syndrome

• Beta blockers may be used cautiously to slow aortic dilatation
• Requires careful monitoring of aortic root dimensions 2

Bicuspid Aortic Valve

• More aggressive monitoring due to accelerated valve degeneration
• May require earlier intervention 2

Pitfalls and Caveats

1. Symptom Recognition: Symptoms may develop insidiously and not correlate with objective evidence of ventricular dysfunction; exercise testing can help identify symptoms related to valve dysfunction 4

2. Vasodilator Efficacy: While vasodilators can improve hemodynamics, long-term studies have shown variable results regarding delaying valve replacement 5

3. Surgical Timing: Delaying surgery until symptoms develop or LV dysfunction occurs may result in irreversible LV damage; regular monitoring is essential to identify the optimal timing for intervention 6

4. Body Size Considerations: Japanese guidelines suggest that LVESD >45 mm is an appropriate cutoff for surgical intervention, while LVESD index of 25 mm/m² may cause overcorrection in patients with smaller body size 7

5. Mixed Valve Disease: When AR coexists with aortic stenosis, more frequent monitoring (every 6 months) is recommended as prognosis is poorer than with isolated valve disease 2

By following this treatment algorithm and monitoring protocol, patients with aortic regurgitation can be managed appropriately to minimize morbidity and mortality associated with this condition.