What is the treatment for severe aortic valve regurgitation?

Treatment of Severe Aortic Regurgitation

Aortic valve replacement (AVR) is indicated for all symptomatic patients with severe aortic regurgitation regardless of left ventricular function, and surgery should not be delayed. 1, 2

Symptomatic Patients

All symptomatic patients with severe AR require AVR immediately, irrespective of LVEF or LV dimensions. 1, 2 This represents a Class I indication across all major guidelines and is the strongest recommendation in AR management. 1

• Symptoms include dyspnea, angina, heart failure, or reduced exercise tolerance. 1
• Surgical risk assessment should not delay intervention in symptomatic patients. 1
• Both mechanical and bioprosthetic valves are acceptable options depending on patient age, anticoagulation tolerance, and informed preference. 1

Asymptomatic Patients with LV Dysfunction

AVR is indicated when LVEF falls below 50-55% in asymptomatic patients, provided no other cause explains the dysfunction. 1, 2

• The ACC/AHA guidelines use LVEF ≤55% as the threshold. 1
• The ESC guidelines use LVEF ≤50% as the threshold. 1
• The JCS guidelines use LVEF <50% as the threshold. 1
• Surgery should be performed before LVEF drops below 50%, as outcomes worsen significantly with lower ejection fractions. 3

Asymptomatic Patients with Severe LV Dilatation

AVR is indicated when left ventricular end-systolic diameter (LVESD) exceeds 50 mm or 25 mm/m² in asymptomatic patients with preserved LVEF. 1, 2

• Alternative thresholds include LVESD >45 mm (reasonable indication per ACC/AHA). 1
• Left ventricular end-diastolic diameter (LVEDD) >65 mm may also trigger consideration for surgery. 1
• Patients with LVEDD ≥81 mm have significantly worse postoperative outcomes, suggesting earlier intervention may be beneficial before reaching this threshold. 3
• Serial imaging every 3-6 months is essential when LV dimensions approach these thresholds. 1

Acute Severe AR

Acute severe AR requires urgent surgical intervention and should not be delayed. 1

• Medical therapy with afterload reduction (vasodilators) may be used for temporary stabilization but must not delay surgery. 1
• Intra-aortic balloon counterpulsation is contraindicated in AR. 1
• Emergency surgery is indicated for hypotension, pulmonary edema, or evidence of low cardiac output. 1

Medical Therapy

Medical therapy has no role in delaying surgery when surgical indications are met, but guideline-directed medical therapy (GDMT) is recommended for patients with prohibitive surgical risk. 1

• ACE inhibitors, ARBs, or sacubitril/valsartan are recommended for patients with LV dysfunction who cannot undergo surgery. 1
• Vasodilators (ACE inhibitors or dihydropyridine calcium channel blockers) may provide symptomatic improvement in severe AR when surgery is not feasible. 1
• Hypertension (systolic BP >140 mmHg) should be treated in asymptomatic patients with chronic AR. 1

Concurrent Cardiac Surgery

AVR is indicated for severe AR in patients undergoing CABG, ascending aorta surgery, or other valve surgery. 1

• AVR is reasonable for moderate AR in patients undergoing other open-heart procedures (Class IIa indication per ACC/AHA). 1
• The ESC considers this a more controversial indication for moderate AR. 1

Aortic Root Surgery

Replacement of the aortic sinuses and/or ascending aorta is reasonable when the aortic dimension is ≥45 mm in patients undergoing AVR for severe AR at comprehensive valve centers. 1

• Valve-sparing surgery may be considered in patients with bicuspid aortic valve and favorable anatomy at experienced centers. 1
• Aortic valve repair is an option in selected patients with suitable anatomy when durable results are expected. 1

Transcatheter Aortic Valve Implantation (TAVI)

TAVI should not be performed in patients with isolated severe AR who are suitable surgical candidates (Class III indication). 1

• TAVI may be considered at experienced centers for selected patients ineligible for surgical AVR. 1
• Post-TAVI AR is a significant complication that can worsen outcomes, particularly in patients with pre-existing LV hypertrophy and reduced compliance. 4

Surveillance for Asymptomatic Patients Not Meeting Surgical Criteria

Patients with severe asymptomatic AR and normal LV function/dimensions require echocardiographic surveillance every 6-12 months. 1

• If LVEF decline or LV dimension increase is observed, repeat imaging should occur every 3-6 months. 1
• Mild-to-moderate AR requires follow-up every 1-2 years. 1
• Exercise testing may help unmask symptoms in apparently asymptomatic patients. 1

Critical Pitfalls to Avoid

• Do not delay surgery in symptomatic patients regardless of LVEF—even severely reduced LVEF (>30%) benefits from surgery. 1
• Do not wait for LVEF to fall below 50% or LVESD to exceed 55 mm, as postoperative outcomes deteriorate significantly at these thresholds. 3
• Do not use medical therapy as a substitute for timely surgical intervention when indications are met. 1, 5
• Do not perform TAVI for native valve AR in surgical candidates—outcomes are inferior to surgical AVR. 1