What are the treatment options for severe aortic regurgitation?

Treatment Options for Severe Aortic Regurgitation

Surgical aortic valve replacement (AVR) is the definitive treatment for severe aortic regurgitation, indicated for all symptomatic patients regardless of left ventricular function, and for asymptomatic patients with left ventricular dysfunction (LVEF <50-55%) or significant left ventricular dilation. 1, 2

Treatment Algorithm Based on Clinical Presentation

Acute Severe Aortic Regurgitation

• Emergency surgical intervention is required 1
• Medical therapy (afterload reduction) may be used temporarily for stabilization
• Surgery should not be delayed, especially with hypotension, pulmonary edema, or low cardiac output
• Intra-aortic balloon counterpulsation is contraindicated 1

Chronic Severe Aortic Regurgitation

Symptomatic Patients (Stage D)

• AVR is indicated regardless of LV systolic function (Class I recommendation) 1, 2
• Surgery should proceed as long as surgical risk is not prohibitive

Asymptomatic Patients with LV Dysfunction

• AVR indicated when LVEF <50-55% if no other cause for LV dysfunction is identified 1, 2
• AVR reasonable when LVESD >50 mm (Class I recommendation) 1
• AVR reasonable when LVESD >45 mm (Class IIa recommendation) 1

Asymptomatic Patients with Preserved LV Function

• AVR may be considered with progressive decline in LVEF on serial studies 1
• AVR may be considered with progressive LV dilation (LVEDD >65 mm) 1
• Regular monitoring with echocardiography is essential 2

Special Considerations

Concurrent Cardiac Surgery

• AVR indicated for severe AR when undergoing CABG or surgery of the ascending aorta/other heart valves 1
• AVR reasonable for moderate AR when undergoing other cardiac surgery 1

Aortic Root Dilation

• If aortic dimension ≥45 mm, replacement of aortic sinuses/ascending aorta is reasonable when performed at a comprehensive valve center 1
• In bicuspid aortic valve patients, valve-sparing surgery may be considered at specialized centers 1

Surgical Options

1. Mechanical or bioprosthetic valve replacement - standard approach 1
2. Valve repair - may be considered in selected patients with favorable anatomy at experienced centers 1
3. Transcatheter aortic valve implantation (TAVI) - may be considered in experienced centers for patients ineligible for surgical AVR 1

Medical Therapy

Medical therapy has a limited role and should not delay surgical intervention when indicated, but may be used in specific situations:

• For patients awaiting surgery: Short-term treatment to improve hemodynamics 2, 3
• For patients with prohibitive surgical risk: GDMT for reduced LVEF including ACE inhibitors, ARBs, and/or sacubitril/valsartan 1
• For asymptomatic patients with normal LV function: Vasodilators (particularly nifedipine) may prolong the compensated phase 3
• For hypertensive patients with AR: ACE inhibitors are particularly useful 3
• For AR with aortic root disease: Beta-blockers may slow aortic dilation 3

Monitoring Parameters for Severe AR

Regular monitoring should include assessment of:

• Symptoms (dyspnea, angina, syncope)
• LV ejection fraction (surgical threshold: <50-55%)
• LV end-systolic diameter (surgical threshold: >45-50 mm)
• LV end-diastolic diameter (concerning if >65 mm)
• Regurgitant volume (≥60 mL/beat indicates severe AR)
• Effective regurgitant orifice area (≥0.3 cm² indicates severe AR) 2

Common Pitfalls to Avoid

1. Delaying surgery until symptoms develop in patients with significant LV dysfunction or dilation - this can lead to irreversible myocardial damage 2, 4
2. Relying solely on symptoms - many patients remain asymptomatic despite severe AR and LV dysfunction 5
3. Using a single echocardiographic parameter to assess AR severity - an integrative approach is required 6
4. Inappropriate use of intra-aortic balloon counterpulsation in acute AR - this is contraindicated 1
5. Overreliance on medical therapy - while vasodilators may be beneficial in certain scenarios, they should not delay indicated surgery 3, 5

Despite higher operative risk in patients with severely reduced LVEF (<35%), most still benefit from AVR with improved postoperative EF and long-term survival, so they should not be denied surgical intervention 4.