Surgical Criteria for Aortic Regurgitation
Surgery is indicated for all symptomatic patients with severe aortic regurgitation regardless of left ventricular function, and for asymptomatic patients with either LVEF ≤50% or severe LV dilatation (LVEDD >70 mm or LVESD >50 mm or >25 mm/m² BSA). 1
Class I Indications (Must Operate)
Symptomatic Patients
- Any symptoms (dyspnea NYHA class II-IV or angina) with severe AR mandate surgery immediately. 1
- Urgent/emergent intervention is required for symptomatic acute severe AR. 1
- Even with marked LV dysfunction or extreme dilatation, surgery should proceed as acceptable operative mortality (3-7%) and symptom improvement can still be achieved. 1
Asymptomatic Patients with LV Dysfunction
- LVEF ≤50% at rest is an absolute indication for surgery. 1
- This threshold prevents irreversible myocardial dysfunction that develops when surgery is delayed further. 1
Concurrent Cardiac Surgery
- Patients undergoing CABG, ascending aorta surgery, or another valve operation must have concomitant aortic valve surgery if severe AR is present. 1
Class IIa Indications (Should Strongly Consider)
Asymptomatic Patients with Severe LV Dilatation
- LVEDD >70 mm 1
- LVESD >50 mm (or >25 mm/m² BSA for patients with small body size) 1
- These dimensional criteria identify patients at high risk for developing irreversible myocardial dysfunction. 1
- Research suggests that LVEDD ≥81 mm or LVEF between 50-55% (even though technically "normal") predicts worse postoperative outcomes, supporting earlier intervention. 2
Rapid Progression on Serial Imaging
- A rapid worsening of ventricular parameters (>2 mm/year increase in dimensions) on serial testing warrants consideration for surgery. 1
- High-quality echocardiograms with repeated measurements and side-by-side comparison using the same imaging technique are essential before operating on asymptomatic patients. 1
Aortic Root Disease Criteria (Independent of AR Severity)
Marfan Syndrome
- Ascending aortic diameter ≥50 mm is a Class I indication for surgery. 1
- ≥45 mm with risk factors (family history of dissection, aortic growth >2 mm/year, severe AR/MR, or desire for pregnancy) is a Class IIa indication. 1
Bicuspid Aortic Valve
- ≥50 mm with risk factors (coarctation, hypertension, family history of dissection, or growth >2 mm/year) is a Class IIa indication. 1
- When severe AR already requires surgery, concomitant aortic replacement should be performed if diameter ≥45 mm. 3
Other Patients
- ≥55 mm ascending aortic diameter is a Class IIa indication. 1
Critical Pitfalls to Avoid
Do Not Delay Surgery in Symptomatic Patients
- Once symptoms develop, mortality increases dramatically from 6% per year to 25% per year. 3
- Delaying surgery after symptom onset leads to irreversible LV dysfunction and reduced long-term survival. 3, 4
Do Not Rely on Single Measurements
- Multiple high-quality echocardiographic measurements with side-by-side comparison are mandatory before recommending surgery in asymptomatic patients. 1, 4
- Confirm findings with repeated measurements using the same imaging technique at the same aortic level. 1
TAVR is NOT an Option for Pure AR
- TAVR should NOT be performed in patients with isolated severe AR who are surgical candidates. 3
- The absence of a calcified landing zone leads to valve malposition, and residual AR >mild doubles 1-year mortality (22% vs 46%). 3
Consider Body Surface Area Indexing
- For patients with small body size, use indexed values: LVESD >25 mm/m² BSA rather than absolute 50 mm cutoff. 1
- This prevents underestimating severity in smaller patients and overestimating in larger patients. 1