In a 58‑year‑old man with chronic severe aortic regurgitation, moderate mitral regurgitation and a left‑ventricular end‑diastolic diameter of 7 cm, what is the optimal management?

Immediate Surgical Intervention is Indicated

This 58-year-old man with severe aortic regurgitation and an LV end-diastolic diameter of 7 cm meets absolute criteria for urgent aortic valve replacement, and the moderate mitral regurgitation should be addressed simultaneously with dual valve surgery. 1

Critical LV Dimensional Thresholds Exceeded

Your patient has crossed multiple surgical thresholds that predict irreversible myocardial dysfunction:

• LV end-diastolic diameter of 70 mm (7 cm) is a Class I indication for surgery in severe AR, regardless of symptoms or ejection fraction 1
• This dimension represents severe LV dilatation that, if left untreated, leads to permanent systolic dysfunction even after valve replacement 1
• The ESC guidelines explicitly state surgery is indicated when LVEDD exceeds 60-65 mm, and your patient is well beyond this at 70 mm 1
• The ACC/AHA guidelines support intervention when LVEDD reaches 65 mm or greater, particularly in low surgical risk patients 1

Dual Valve Surgery is Recommended

The presence of moderate MR alongside severe AR necessitates addressing both valves:

• When severe AR requires surgery and moderate MR coexists, dual valve surgery is reasonable (Class IIa recommendation) to avoid leaving significant MR unoperated 1
• The JCS guidelines recommend dual valve surgery when patients have more than moderate AR in the setting of severe MR, and this principle applies reciprocally 1
• Leaving moderate MR unaddressed at the time of AVR risks progression and need for redo surgery, which carries substantially higher operative mortality 2
• Combined aortic and mitral regurgitation creates compounded volume overload on the LV, accelerating dysfunction 2, 3

Why This Dimension Mandates Surgery

The pathophysiology explains the urgency:

• AR creates both volume and pressure overload with high driving pressures throughout the entire cardiac cycle, leading to both parallel and serial sarcomere replication 3
• At 70 mm LVEDD, the myocardium has undergone extensive remodeling with increased wall stress and early fibrosis 4
• Operative mortality remains acceptable (1-3%) when surgery is performed before irreversible LV dysfunction develops, but rises dramatically to 3-7% once severe dysfunction occurs 1
• Delaying surgery beyond this dimensional threshold results in persistent LV dysfunction postoperatively, even with successful valve replacement 1

Surgical Approach and Timing

Proceed with the following algorithm:

• Refer immediately to a cardiac surgery center with a multidisciplinary heart valve team for evaluation within 2-4 weeks 2
• Assess for symptoms (dyspnea, angina, reduced exercise tolerance) which would upgrade this to Class I urgent indication if present 1, 5
• Obtain current LVEF measurement—if LVEF is ≤55%, this becomes an additional Class I indication for immediate surgery 1, 5
• If LVEF is ≤50%, this represents established LV systolic dysfunction requiring urgent intervention 1
• Evaluate aortic root dimensions—if root diameter exceeds 50-55 mm, concomitant root replacement should be performed 1, 5

Preoperative Medical Management

While awaiting surgery (which should not be delayed):

• Initiate or optimize ACE inhibitors or ARBs to reduce systolic blood pressure and LV afterload, targeting systolic BP <140 mmHg 5, 6, 7
• Avoid beta-blockers, as they prolong diastolic filling time and paradoxically increase regurgitant volume 5, 7
• Dihydropyridine calcium channel blockers are an alternative vasodilator if ACE inhibitors are not tolerated 5, 7
• Ensure optimal volume status—avoid excessive diuresis which reduces forward stroke volume 4

Critical Pitfalls to Avoid

• Do not delay surgery to "watch and wait"—at 70 mm LVEDD, further delay risks irreversible myocardial damage 1
• Do not perform isolated AVR without addressing the moderate MR—this increases the likelihood of requiring redo mitral surgery 1, 2
• Do not rely solely on symptoms—this patient may be asymptomatic due to gradual adaptation, but dimensional criteria alone mandate intervention 1
• Do not use medical therapy as a substitute for surgery—vasodilators may temporarily improve hemodynamics but cannot prevent progressive LV dysfunction at this stage 5, 4

Expected Outcomes

With timely dual valve surgery:

• Operative mortality should be 3-7% for combined valve procedures in experienced centers 1
• LV dimensions typically regress postoperatively, though complete normalization may not occur given the degree of pre-existing dilatation 4
• Long-term survival approaches that of age-matched controls when surgery is performed before LVEF falls below 50% 1, 8
• Functional status improves significantly, with most patients achieving NYHA Class I-II 1

The combination of severe AR with LVEDD of 70 mm represents a narrow window for intervention before irreversible myocardial damage occurs—surgery should proceed without delay. 1