What does Avvr (aortic valve regurgitation) on an echocardiogram indicate and how is it managed?

Aortic Valve Regurgitation (AVVR) on Echocardiogram

Aortic valve regurgitation on echocardiogram indicates diastolic backflow of blood from the aorta into the left ventricle, requiring immediate assessment of severity, left ventricular dimensions, and systolic function to determine the need for surgical intervention. 1

What AVVR Indicates

Hemodynamic Significance:

• AVVR represents volume overload on the left ventricle, causing progressive LV dilation and eccentric hypertrophy over time 2
• The condition creates combined LV volume and pressure overload with systolic hypertension and wide pulse pressure 2
• Chronic severe AR allows patients to remain asymptomatic for years through ventricular remodeling, but this compensation eventually fails 3, 2

Severity Grading Parameters:

• Effective regurgitant orifice area (EROA), regurgitant volume, and vena contracta width are critical quantitative measures 1
• Vena contracta width ≥0.6 cm indicates severe AR 4
• Transthoracic echocardiography (TTE) is the primary diagnostic modality for assessing AR severity, cause, LV size, and systolic function 1

Management Strategy by Disease Stage

Stage A (At Risk):

• Patients with bicuspid aortic valve require initial TTE to assess aortic root and ascending aorta diameters 1
• If aortic root or ascending aorta diameter >4.0 cm, perform yearly serial echocardiography 1

Stage B (Progressive Mild-to-Moderate AR):

• Clinical visits annually with detailed history and physical examination 4
• Echocardiography every 2-3 years for mild AR if asymptomatic with stable LV size and function 4
• Echocardiography every 1-2 years for moderate AR to monitor progression and LV remodeling 4
• No surgical intervention indicated for mild or moderate AR with normal LV function and dimensions 1

Stage C (Severe Asymptomatic AR):

• Aortic valve replacement (AVR) is indicated when:
  • LV ejection fraction ≤50% at rest 1
  • LV end-systolic dimension ≥55 mm 1
  • LV end-diastolic dimension ≥75 mm 1
• AVR is reasonable when:
  • LV end-systolic dimension >55 mm with normal ejection fraction 1
  • LV end-diastolic dimension >75 mm with normal ejection fraction 1
• AVR may be considered when:
  • LV end-systolic dimension 50-55 mm with progressive LV dilatation, declining exercise tolerance, or abnormal hemodynamic response to exercise 1
  • LV end-diastolic dimension 70-75 mm with evidence of progression 1
• Indexed LV end-systolic volume ≥45 mL/m² is associated with worse outcomes and higher symptom prevalence 5

Stage D (Symptomatic Severe AR):

• AVR is indicated immediately for any symptoms attributable to severe AR 1, 2
• Symptomatic patients should undergo surgery as soon as possible unless excessive comorbidities exist 1, 3
• Surgery should be performed before LV ejection fraction falls below 55% or LV end-systolic dimension reaches 55 mm 2

Critical Monitoring Parameters

Echocardiographic Follow-Up:

• Asymptomatic severe AR with normal LV function: every 6 months initially, then yearly if stable 4
• Severe LV dilatation (end-diastolic dimension >70 mm): every 6 months 3
• Moderate LV enlargement: yearly intervals 3
• After AVR: within first few weeks, then at 6 and 12 months, then yearly if uncomplicated 1

Key Measurements at Each Echo:

• LV end-diastolic and end-systolic dimensions (linear measurements) 1
• LV end-diastolic and end-systolic volumes (more accurate than linear dimensions) 5
• LV ejection fraction 1
• Effective regurgitant orifice area and regurgitant volume 4
• Aortic root size if dilated 1

Special Considerations

Elderly Patients:

• Patients >75 years develop symptoms and LV dysfunction at earlier stages of LV dilatation 1
• More persistent ventricular dysfunction and heart failure symptoms after surgery with worse postoperative survival 1
• Symptoms are the most important guide for determining AVR timing, as the goal is improving quality of life 1

Concomitant Procedures:

• AVR is indicated for chronic severe AR when undergoing CABG or surgery on the aorta or other heart valves 1
• AVR may be considered for moderate AR during CABG or ascending aorta surgery 1
• Coronary angiography is indicated before AVR in patients at risk for CAD 1

Postoperative Assessment:

• 80% of overall reduction in LV end-diastolic dimension occurs within first 10-14 days after AVR 1
• Reduction in LV end-diastolic dimension is a better predictor of subsequent LV systolic function than early ejection fraction changes 1
• Persistent LV dilatation on initial postoperative echo warrants treatment with ACE inhibitors and beta-blockers 1

Common Pitfalls

Avoid these errors:

• Do not rely solely on linear dimensions; LV volumes correlate better with outcomes (correlation coefficients only 0.5-0.6 between volumes and linear dimensions) 5
• Do not delay surgery in symptomatic patients—symptoms indicate immediate need for AVR 1, 2
• Do not assume mild AR on auscultation is accurate; echocardiography has 21% sensitivity but 96% specificity for detecting AR 1
• Do not perform cardiac catheterization when noninvasive tests are adequate and concordant with clinical findings 1
• Do not ignore aortic root dilatation; serial echocardiograms are required to evaluate both root size and AR severity 1