Surgical Options for Aortic Valve Repair/Replacement in Severe Aortic Regurgitation
For patients with severe aortic regurgitation without stenosis, surgical aortic valve replacement (SAVR) with either a mechanical or bioprosthetic valve is the primary recommended intervention, while valve repair may be considered in selected patients with favorable valve anatomy at experienced centers. 1
Primary Surgical Options
Aortic Valve Replacement (AVR)
- Mechanical valve replacement: Durable option typically preferred in younger patients due to excellent long-term durability, though requires lifelong anticoagulation 1
- Bioprosthetic valve replacement: Doesn't require long-term anticoagulation, making it increasingly popular, especially in older patients 1
- AVR is indicated in symptomatic patients with severe AR regardless of left ventricular function (Class I recommendation) 1
- AVR is indicated in asymptomatic patients with severe AR and LV systolic dysfunction (LVEF <50-55%) if no other cause for dysfunction is identified 1
Aortic Valve Repair
- Valve-sparing procedures: May be considered in patients with favorable valve anatomy who are undergoing surgical replacement of the aortic sinuses and/or ascending aorta 1
- Aortic valve repair may be considered in selected patients at experienced centers, particularly when the aortic root is being addressed 1
- Valve-sparing surgery may be considered in patients with bicuspid aortic valve who meet criteria for replacement of aortic sinuses, if performed at a comprehensive valve center 1
Special Considerations
Concurrent Aortic Root Disease
- If surgery is indicated for severe AR and aortic dimension is ≥45 mm, replacement of the aortic sinuses and/or ascending aorta is reasonable when performed at a comprehensive valve center 1
- In patients with bicuspid aortic valve, valve-sparing surgery may be considered if performed at a comprehensive valve center 1
Concurrent Cardiac Surgery
- AVR is indicated in patients with severe AR undergoing CABG or surgery of the ascending aorta or other heart valves 1
- AVR is reasonable for patients with moderate AR (stage B) who are undergoing cardiac surgery for other indications 1
Transcatheter Options
- Transcatheter aortic valve replacement (TAVR) should NOT be performed in patients with isolated severe AR who have indications for SAVR and are surgical candidates (Class III: Harm recommendation) 1
- TAVR may be considered in experienced centers for selected patients ineligible for SAVR 1
- Valve-in-valve transcatheter procedures are emerging as an option for patients with failed bioprosthetic valves who are at high surgical risk 2, 3, 4
Comparison to Mitral Valve Repair
Aortic valve procedures are generally not less invasive than mitral valve repair:
- Both aortic and mitral valve surgeries typically require a median sternotomy and cardiopulmonary bypass 1
- Mitral valve repair is often preferred over replacement when feasible, as it preserves the native valve apparatus 1
- Aortic valve repair is technically more challenging than mitral valve repair and is performed less frequently 1
- Transcatheter options for native aortic regurgitation are more limited compared to those available for mitral regurgitation 1
Risk Assessment and Decision-Making
High-risk SAVR is defined by factors including:
- Predicted risk of death >8%
- Moderate to severe frailty
- Significant comorbidities
- Poor mobility 1
Prohibitive-risk SAVR is defined by:
- Predicted all-cause mortality >50% at 1 year
- Severe frailty
- Multiple organ system compromise 1
Follow-up and Surveillance
- Asymptomatic patients with severe AR should undergo clinical and echocardiographic follow-up every 6-12 months 1
- More frequent monitoring (3-6 months) is recommended if there is progressive LV enlargement or decline in LVEF 1