Approach

Acute AR is an emergency requiring urgent surgical intervention. Chronic AR has a protracted course and the patient may remain asymptomatic for decades. Many of those who have mild or moderate AR remain stable and may never require any corrective surgery. Surgery should be performed as soon as possible in patients with chronic AR who develop haemodynamic instability or heart failure.

Acute AR

Acute AR is a surgical emergency. Patients require assessment and management of the airway, with intubation if necessary. Positive inotropic agents (e.g., dobutamine) and a vasodilator (e.g., sodium nitroprusside) are recommended for haemodynamic support. The definitive management is with urgent surgery, especially for patients with AR resulting from infective endocarditis and aortic root dissection.[1][22]

Chronic AR

The treatment of chronic AR depends on 5 factors:

  • Whether the regurgitation is mild, moderate, or severe

  • Whether the patient is asymptomatic or symptomatic

  • Whether the patient has normal left ventricular (LV) function or LV dysfunction

  • Whether the patient has LV dilation

  • Whether the patient is a surgical candidate.

Mild to moderate disease

Patients with mild to moderate disease (American College of Cardiology/American Heart Association [ACC/AHA] stage B, progressive AR) who are asymptomatic with normal LV function do not require treatment and can be reassured. In patients with this degree of AR severity, symptoms or LV dysfunction, if present, are unlikely to be due to AR. An alternative underlying cause such as hypertension, coronary artery disease, or a cardiomyopathy is more likely and should be investigated and treated. Periodic follow-up for symptom and functional status evaluation is recommended.

In patients with moderate disease who are undergoing cardiac surgery for another indication, concomitant aortic valve replacement can be considered.[1]

Severe disease

Patients who have asymptomatic AR with LV ejection fraction (LVEF) >55% and LV end-systolic diameter (LVESD) <50 mm (ACC/AHA stage C1) require no treatment and the patient can be reassured. Periodic follow-up for symptom and functional status evaluation is recommended. If the patient is undergoing cardiac surgery for another indication, concomitant aortic valve replacement can be considered.[1]

Note that in European Society of Cardiology (ESC) guidelines, the threshold for intervention in asymptomatic patients is LVEF <50%.[22]

Aortic valve surgery is indicated in asymptomatic patients with chronic severe AR and LVEF ≤55% (ACC/AHA stage C2), if no other cause for systolic dysfunction is identified. Aortic valve surgery is also reasonable in patients with normal LV systolic function (LVEF >55%) when the LV is severely enlarged (LVESD >50 mm or indexed LVESD >25 mm/m²).[1][26] Surgery can also be considered in patients with chronic severe AR and LVEF >55% at rest (ACC/AHA stage C1) who have a low surgical risk and a progressive decline in LVEF to low-normal range (55% to 60%) or progressive increase in LV end-diastolic diameter (>65 mm) on at least 3 studies.[1]

In patients who have severe AR with LV systolic dysfunction and/or symptoms but a prohibitive surgical risk, guideline-directed medical therapy (GDMT) for reduced LVEF and/or hypertension is recommended.[1]

All symptomatic patients require surgery, regardless of their LV function and dilation.[1][22][26] Vasodilators may be used for symptomatic management while the patient is awaiting surgery.[1] If the patient is not a surgical candidate due to comorbidities, GDMT for reduced LVEF and/or hypertension is recommended.[1]

The surgical options are aortic valve replacement (AVR) or repair. There is no difference in the indications for replacement or repair. AVR is performed in most patients requiring surgery. Aortic valve repair is possible in selected patients but is only performed in specialist centres. Following surgery, most of the patients show reversal of LV dilation and improvement in EF. Preoperative LV function is the best predictor of long-term prognosis in patients undergoing AVR.[27] Patients with normal preoperative EF or a brief duration of LV dysfunction (<14 months) have greater improvement in LV diameters and early and late postoperative improvement in LV function.[28] Among patients with LV dysfunction, patients with impaired preoperative LV function have a greater risk of developing congestive heart failure and are at a higher risk of death compared with patients with normal preoperative LV function.[29] Survival among patients with preoperative severe LV dysfunction has improved dramatically since 1985 and has become almost equivalent to that among patients with non-severe LV dysfunction. Prosthetic valve patients are at high risk for thromboembolism and need antithrombotic therapy. The risk of bleeding must be weighed against the benefit of anticoagulation.

Transcatheter aortic valve implantation (TAVI) can be considered for carefully selected patients with severe AR and heart failure who are not surgical candidates, but it is rarely done.[1][22] TAVI is not recommended for those with isolated severe AR who have indications for surgery and are candidates for surgery.[1]

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