Management and Treatment of Aortic Regurgitation

Immediate Surgical Intervention for Symptomatic Patients

All symptomatic patients with severe aortic regurgitation require surgical aortic valve replacement regardless of left ventricular function—this represents the strongest consensus across all major guidelines (ACC/AHA, ESC, JCS) and is the only definitive treatment that reduces mortality. 1, 2

Why Surgery Cannot Be Delayed in Symptomatic Patients

Once symptoms develop (exertional dyspnea, fatigue, palpitations), annual mortality rises dramatically to 10-25%, making symptom onset an absolute indication for surgery. 3, 4
Symptoms herald left ventricular decompensation and represent the strongest indication for intervention. 1, 3
Never delay surgery to "optimize" medical therapy in symptomatic patients—symptoms indicate decompensation and mortality risk increases substantially. 4
Within 10 years of diagnosis of severe AR, 75% of patients die or require aortic valve replacement. 3

Acute vs. Chronic Symptomatic Presentations

Acute AR causes severe pulmonary edema and hypotension requiring emergency surgery due to sudden volume overload on a non-compliant left ventricle that has not had time to adapt. 3, 4
Medical therapy in acute AR serves only as a temporary bridge to emergency surgery and should never delay surgical intervention. 4
Chronic symptomatic AR progresses insidiously with exertional dyspnea typically being the first symptom, developing as compensatory mechanisms fail. 3

Surgical Intervention for Asymptomatic Patients

Surgery is indicated in asymptomatic patients when there is evidence of LV systolic dysfunction or significant LV dilatation, as these markers predict poor outcomes. 2, 4

Specific Thresholds Triggering Surgery

LV ejection fraction ≤50-55% 4
LV end-systolic diameter >50 mm or >25 mm/m² BSA 1, 2
LV end-diastolic diameter >60 mm 2
ESC guidelines suggest considering intervention in patients with LVESDI >20 mm/m² BSA when surgical risk is low, as this threshold is associated with increased mortality. 1

Progressive LV Dilatation on Serial Imaging

When LVEF is preserved, most guidelines advocate intervention when there is LV dilatation, especially when progressive on serial imaging. 1
This requires echocardiography every 6-12 months in asymptomatic severe AR to monitor for LV dysfunction or progressive dilatation. 4
More frequent monitoring (every 3-6 months) is warranted if LVEF begins declining or end-systolic dimensions increase. 4

Surgical Options: Replacement vs. Repair

Aortic Valve Replacement (First-Line)

Surgical aortic valve replacement remains the mainstay intervention for severe aortic regurgitation. 1, 2
AVR is indicated for all patients with symptomatic severe AR regardless of LV function. 2

Aortic Valve Repair (Selected Cases)

Aortic valve repair may be considered in specialist centers for anatomically suitable patients when durable results are expected. 2
Root replacement with valve-sparing techniques appears durable and safe, particularly for AR driven by aortic root dilatation. 1
In bicuspid aortic valve patients (2% of population), AV repair has been an appealing alternative to AVR in younger patients, though reintervention rates reach 20% at 10 years. 1
Data remain limited to case series and meta-analyses, with techniques varying across centers. 1

Transcatheter Aortic Valve Intervention (TAVI)

TAVI has been successfully used for patients where surgical risk is prohibitive, showing potential as an alternative when prognosis is poor with conservative treatment alone. 1
AR is traditionally a contraindication to TAVI as the calcified landing zone is often lacking, potentially leading to malposition and paravalvular leak. 1

Medical Management: When and What to Use

Indications for Medical Therapy

Medical therapy is indicated in three specific scenarios: 1, 2

Asymptomatic patients with severe AR and normal LV function to prolong the compensated phase and delay surgery
Symptomatic patients in whom surgery is not feasible (contraindicated or refused)
Post-operative patients with persistent heart failure or hypertension

Specific Medications and Dosing

ACE Inhibitors or Angiotensin Receptor Blockers (First-Line)

Recommended for blood pressure control and heart failure management. 2, 4
Particularly useful for hypertensive patients with AR. 5
ACE inhibitors may prolong the compensated phase and delay need for surgery in asymptomatic patients with normal LV function. 4

Dihydropyridine Calcium Channel Blockers

Nifedipine 30-90 mg daily is the best evidence-based treatment for asymptomatic severe AR with normal LV function. 4, 5
Can be used as vasodilators for blood pressure management. 2
Nifedipine may prolong the compensated phase and delay need for surgery in asymptomatic patients. 4

Blood Pressure Targets

Target systolic blood pressure should be <140 mmHg using vasodilators that do not slow heart rate. 2, 4
The goal is to reduce left ventricular wall stress and afterload. 4

Acute AR Bridge to Surgery

Vasodilators such as sodium nitroprusside or intravenous nitroglycerin should be administered immediately to reduce LV afterload and improve forward flow. 4

Critical Medications to AVOID

Beta-Blockers Are Contraindicated

Beta-blockers should be avoided as they prolong diastole and increase regurgitant volume, potentially worsening aortic regurgitation. 2, 4

This is a firm recommendation from both the European Society of Cardiology and American College of Cardiology. 2, 4
Do not use beta-blockers for rate control or blood pressure management in AR, as they worsen hemodynamics by prolonging diastole. 4
The exception is in patients with AR associated with aortic root disease, where beta-blockers may slow the rate of aortic dilatation. 5

Diuretic Caution

Avoid aggressive diuresis in patients with small left ventricular chambers, as preload reduction can compromise cardiac output. 4

Concurrent Cardiac Surgery

Patients with symptomatic and asymptomatic severe AR undergoing CABG, another valve surgery, or surgery of the ascending aorta should have surgical intervention of AR at the time of the operation. 1

This represents consensus across ACC/AHA, ESC, and JCS guidelines. 1

Post-Operative Management and Surveillance

Continued Medical Therapy

Continue guideline-directed medical therapy for persistent heart failure or hypertension after surgery. 2
Optimal guideline-directed medical therapy for heart failure and hypertension is useful when surgery is contraindicated or refused. 2

Surveillance Requirements

Post-operative patients need continued surveillance for residual or recurrent aortic regurgitation and persistent LV dysfunction. 2
Patients managed medically require 6-12 monthly echocardiographic follow-up to detect progression. 2

Diagnostic Approach

Echocardiography (Primary Modality)

Echocardiography is the key imaging modality to diagnose AR, define its etiology, and grade its severity. 1
Key parameters supporting severe AR include vena contracta >0.6 cm, EROA ≥0.3 cm², regurgitant volume ≥60 mL/beat, holodiastolic flow reversal in descending aorta, and LV dilatation (LVESD >50 mm or >25 mm/m²). 1

Complementary Imaging

CT may be appropriate to obtain aortic root dimensions and exclude dissection in acute AR. 1
CMR imaging can assess biventricular volumes and systolic function, aortic size, and regurgitant fraction, and complements assessment of AR severity where there is diagnostic uncertainty. 1
CMR is the reference standard for quantifying LV volumes and systolic function. 1

Emerging Biomarkers

Global longitudinal strain (GLS) between certain thresholds is associated with worse cardiac outcomes (death or progression to AVR) in asymptomatic AR. 1
NT-proBNP may be a useful additional prognostic marker as it correlates well with AR severity and mortality. 1
Closer monitoring of high-risk patients may allow early identification of decompensation before irreversible cardiac damage. 1

What are the management and treatment options for a patient with aortic regurgitation?

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