From the Research
Patients with severe aortic regurgitation (AR) and low ejection fraction (EF) face a surgical mortality rate of approximately 5-15%, with the most recent study 1 showing a mortality rate of 27.8% in the aortic valve replacement (AVR) group.
Key Considerations
- The natural history of severe AR without intervention carries a higher mortality rate, making AVR the definitive treatment despite the elevated surgical risk.
- Preoperative optimization is crucial and should include afterload reduction with ACE inhibitors (e.g., enalapril 5-20 mg twice daily) or ARBs (e.g., losartan 25-100 mg daily), and possibly inotropic support in decompensated cases.
- Careful surgical planning with a heart team approach is essential, considering transcatheter options in high-risk patients.
Management Strategies
- Earlier intervention before significant LV dysfunction develops is ideal but not always possible.
- Postoperatively, continued heart failure management is necessary, including beta-blockers (e.g., carvedilol 3.125-25 mg twice daily) and diuretics as needed, with close monitoring of ventricular recovery, which may take 6-12 months in some patients.
- The study by 2 suggests that an ejection fraction <50% and an LV end-systolic diameter (LVESD) >45 mm are appropriate cutoff values for surgical intervention in patients with severe chronic AR.
Recent Evidence
- A study published in 2018 1 found that AVR was associated with lower mortality (HR=0.143, p=0.0490) in patients with severe AR and low LVEF, despite the high surgical risk.
- The most recent study 2 provides evidence for the optimal management of chronic severe AR, highlighting the importance of determining cutoff values for surgical intervention based on LV dysfunction and symptoms.