What is the significance of mild Aortic Regurgitation (AR) in a 2-dimensional (2D) echocardiography of an asymptomatic patient?

From the Guidelines

Mild Aortic Regurgitation (AR) in a 2-dimensional (2D) echocardiography of an asymptomatic patient is not a significant concern and can be monitored with yearly clinical evaluation and echocardiography every 2-3 years 1.

Key Points

• The patient is asymptomatic, which is a crucial factor in determining the management of AR.
• Mild AR is defined as a jet width <25% of LVOT, vena contracta <0.3 cm, regurgitant volume <30 mL/beat, regurgitant fraction <30%, and ERO <0.10 cm² 1.
• The management of patients with AR depends on an accurate diagnosis of the disease, and the severity of the valvular regurgitation, the degree of LV dilatation, and the level of systolic function 1.
• Asymptomatic patients with mild AR, little or no LV dilatation, and normal LV systolic function can be seen on a yearly basis, with instructions to alert the physician if symptoms develop in the interim 1.
• Yearly echocardiography is not necessary unless there is clinical evidence that regurgitation has worsened 1.
• The aim of serial evaluation of asymptomatic patients with chronic AR is to detect the onset of symptoms and objectively assess changes in LV size and function that can occur in the absence of symptoms 1.
• Severe AR is associated with significant cardiovascular morbidity and mortality, but mild AR is not typically associated with these outcomes 1.
• The decision to operate on asymptomatic patients with severe AR and impaired LV function at rest should be based on individual patient characteristics and the presence of other indications for surgery 1.
• In patients with mild AR, the focus should be on monitoring for progression of the disease and development of symptoms, rather than immediate surgical intervention 1.

From the Research

Significance of Mild Aortic Regurgitation in 2D Echocardiography

• Mild Aortic Regurgitation (AR) is generally considered benign in individuals with normal Left Ventricular (LV) dimensions 2.
• In asymptomatic patients, even severe AR is not generally associated with increased morbidity or mortality before LV dimensions increase 2.
• The significance of mild AR in 2D echocardiography lies in its potential to progress to more severe forms of the disease, which can lead to LV enlargement and increased morbidity and mortality 2, 3.
• Echocardiography is instrumental in the assessment of AR, enabling the delineation of valvular morphology, the mechanism of the lesion, and the grading of severity 4.

Diagnosis and Management

• Two-dimensional echocardiography is useful in determining the origin of aortic regurgitation and can detect causes of acute aortic regurgitation such as bacterial endocarditis, flail aortic valve, and dissecting aneurysm 5.
• Echocardiography can also assess the severity of AR and predict optimal time for surgery in patients with chronic aortic regurgitation 5.
• Novel echocardiographic methods, such as global longitudinal strain and three-dimensional echocardiography, can provide invaluable information for patient management and prognosis 4.
• Doppler-derived echo indices, such as diastolic flow reversal velocity and 3D vena contracta area, can be used to quantify AR severity and correlate with cardiac magnetic resonance parameters 6.

Progression of Aortic Regurgitation

• Progressive dilation of the aortic root at all levels can occur even in patients with mild AR 3.
• More rapid progression in aortic root size is associated with more rapid progression of the underlying aortic insufficiency, as well as more rapid increases in LV volume and mass 3.
• The rate of change of the supraaortic ridge, the upper support structure of the anulus and cusps, is faster in patients with more severe degrees of AR 3.