What is the treatment for aortic regurgitation?

Treatment of Aortic Regurgitation

Surgical intervention is the definitive treatment for aortic regurgitation, with specific indications based on symptoms, left ventricular function, and ventricular dimensions. 1, 2

Indications for Surgical Intervention

Symptomatic Patients

• Surgery is indicated for all symptomatic patients with severe AR regardless of LV function 1
• Surgical intervention is the only life-saving treatment in acute severe AR 3

Asymptomatic Patients with Severe AR

Surgical intervention is indicated when:

• LVEF ≤50-55% 1, 2
• LVESD >50 mm or >25 mm/m² 1, 2
• LVEDD >65 mm 2
• Progressive decline in LVEF on serial studies 1
• Progressive increase in LV dilatation into severe range 1

Concurrent Cardiac Surgery

• Surgery is indicated in patients with severe AR undergoing:
  • Coronary artery bypass grafting (CABG)
  • Other valve surgery
  • Surgery of the ascending aorta 1, 2
• Reasonable to consider surgery for moderate AR in patients undergoing other cardiac procedures 1

Surgical Options

1. Surgical Aortic Valve Replacement (SAVR):

   • Main surgical intervention for severe AR 1
   • Options include mechanical or bioprosthetic valves

2. Aortic Valve Repair:

   • May be considered in anatomically suitable patients when durable results are expected 1
   • Should be performed in experienced centers with high repair rates 1

3. Valve-Sparing Root Surgery:

   • Option for patients with aortic root disease 2

4. Transcatheter Aortic Valve Replacement (TAVR):

   • May be considered for high surgical risk patients 2
   • Not commonly used for pure AR 4

Medical Therapy

Role in Chronic AR

• Primary purpose: To optimize patients before surgery or manage those who are not surgical candidates 1, 2
• Vasodilators (ACE inhibitors, ARBs, dihydropyridine calcium channel blockers):
  • Useful in patients with hypertension 1, 2, 3
  • Beneficial when surgery is contraindicated 1
  • May help when LV dysfunction persists postoperatively 1
  • Nifedipine has the best evidence for delaying surgery in asymptomatic patients with normal LV function 3

Specific Medications

• ACE inhibitors/ARBs: First-line for hypertensive patients with AR 2
• Dihydropyridine calcium channel blockers: Reduce LV volume and mass and improve LV performance 2
• Beta-blockers:
  • Generally avoided in chronic AR as they may worsen regurgitation by increasing diastolic filling period 2
  • Exception: Patients with Marfan syndrome where they may slow aortic root dilatation 1, 2

Medication Considerations

• Start at low doses and gradually titrate upward 2
• Avoid marked reduction in diastolic BP, which may lower coronary perfusion pressure 2

Monitoring and Follow-up

Frequency of Monitoring

• Severe asymptomatic AR: Every 6-12 months 1, 2
• Moderate AR: Every 1-2 years 1, 2
• Mild AR: Every 3-5 years 1, 2
• More frequent monitoring (every 3-6 months) if:
  • Decline in LVEF
  • Increase in LV size 1, 2

Imaging Modalities

• Transthoracic echocardiography is the primary diagnostic method 2
• Consider multimodality imaging (CMR, CT) when:
  • Discrepancy between symptoms and echofindings
  • Need to assess aortic dimensions 1

Special Considerations

Aortic Root Disease

• Surgery indicated when maximal ascending aortic diameter:
  • ≥50 mm for patients with Marfan syndrome 1
  • ≥45 mm for patients with Marfan syndrome with risk factors 1
  • ≥50 mm for patients with bicuspid valve with risk factors 1
  • ≥55 mm for other patients 1

Mixed Valve Disease

• Requires careful assessment to identify predominant valve pathology 1
• In symptomatic patients with combined AR and aortic stenosis with peak velocity ≥4.0 m/s, AVR is recommended 1

Non-cardiac Surgery

• Can be performed safely in asymptomatic severe AR with preserved LV function 1
• If LVEF <30% and/or pulmonary artery systolic pressure ≥50-60 mmHg, elective non-cardiac surgery should only be performed after optimization of medical therapy and only if strictly necessary 1

Pitfalls and Caveats

1. Delayed Intervention: Waiting too long for surgical intervention can lead to irreversible LV dysfunction and worse outcomes 4

2. Over-reliance on Symptoms: Disease progression is often insidious, and symptoms may not correlate with objective evidence of ventricular dysfunction 5

3. Inadequate Follow-up: Regular monitoring is essential as progression occurs at variable rates 5

4. Body Size Considerations: LVESD index of 25 mm/m² may cause overcorrection in patients with smaller body size (e.g., Japanese population) 6

5. Acute AR: Represents a surgical emergency requiring immediate intervention; presents with severe pulmonary edema and hypotension 2, 7