What is the treatment for aortic regurgitation?

Treatment of Aortic Regurgitation

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

Indications for Surgery

Surgery is indicated in the following scenarios:

• All symptomatic patients with severe aortic regurgitation regardless of left ventricular function 1
• Asymptomatic patients with:
  • Left ventricular ejection fraction (LVEF) ≤50-55% 1
  • Left ventricular end-systolic diameter (LVESD) >50 mm or >25 mm/m² 1
  • Progressive decline in LVEF on serial studies 1
  • Progressive increase in left ventricular dilatation into severe range 1
• Patients with severe aortic regurgitation undergoing other cardiac surgeries (CABG, other valve surgery, or ascending aorta surgery) 1
• Patients with moderate aortic regurgitation undergoing other cardiac procedures 1

Surgical Options

1. Surgical Aortic Valve Replacement (SAVR):

   • Primary surgical intervention for severe aortic regurgitation
   • Options include mechanical or bioprosthetic valves 1

2. Aortic Valve Repair:

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

3. Valve-Sparing Root Surgery:

   • Option for patients with aortic root disease 1

4. Transcatheter Aortic Valve Replacement (TAVR):

   • May be considered for high surgical risk patients with severe aortic regurgitation 1

Medical Management

Medical therapy serves primarily to optimize patients before surgery or manage those who are not surgical candidates:

1. Vasodilators:

   • ACE inhibitors, ARBs, and dihydropyridine calcium channel blockers are useful in patients with hypertension 1
   • May be beneficial when surgery is contraindicated or when LV dysfunction persists postoperatively 1
   • First-line agents for hypertensive patients with aortic regurgitation 1

   Despite theoretical benefits, long-term vasodilator therapy with nifedipine or enalapril did not reduce or delay the need for aortic-valve replacement in patients with asymptomatic severe aortic regurgitation and normal left ventricular function 2

2. Beta-blockers:

   • Should generally be avoided in chronic aortic regurgitation as they may increase diastolic filling period due to bradycardia, potentially worsening aortic insufficiency 1
   • Can be used in patients with Marfan syndrome to slow aortic dilatation (with caution in severe aortic insufficiency) 1
   • May be appropriate in patients with severe left ventricular dysfunction 1

Monitoring and Follow-up

Frequency of monitoring depends on disease severity:

• Severe asymptomatic aortic regurgitation: every 6-12 months 1
• Moderate aortic regurgitation: every 1-2 years 1
• Mild aortic regurgitation: every 3-5 years 1
• More frequent monitoring (every 3-6 months) if there is a decline in LVEF or an increase in left ventricular size 1

Special Considerations

1. Aortic Root Disease:

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

2. Acute Aortic Regurgitation:

   • Surgical emergency requiring immediate intervention
   • Presents with severe pulmonary edema and hypotension 1, 3

3. Combined Aortic Regurgitation and Stenosis:

   • In symptomatic patients with combined disease and peak velocity ≥4.0 m/s, aortic valve replacement is recommended 1

4. Non-cardiac Surgery:

   • Can be performed safely in asymptomatic severe aortic regurgitation with preserved LV function
   • 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

Common Pitfalls and Caveats

• Relying solely on symptoms to guide surgical timing can lead to irreversible LV dysfunction, as symptoms often develop late in the disease course 3, 4
• Single echocardiographic measurements should not be the sole basis for recommending surgery; consistent findings on repeat measurements are more reliable 4
• Exercise testing can help identify symptoms that may not be apparent at rest 5
• While vasodilators theoretically reduce afterload and improve LV performance, evidence for their ability to delay surgery is limited 2, 6
• Beta-blockers, while beneficial in many cardiovascular conditions, may worsen aortic regurgitation by prolonging diastole 1