Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute AR

1st line – inotropes + vasodilators + urgent aortic valve replacement/repair

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ACUTE
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acute AR
1st line – 

inotropes + vasodilators + urgent aortic valve replacement/repair

Acute AR is a surgical emergency.[1][22] Hemodynamic support with inotropic agents and vasodilators may be necessary for stabilization. 

Aortic valve replacement or repair should be performed as soon as possible. Aortic valve repair is possible in selected patients, but is only performed in specialist centers.

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.

Intravenous infusion rates >10 micrograms/kg/minute may lead to cyanide toxicity with nitroprusside.

Primary options

dobutamine: 0.5 micrograms/kg/min intravenously initially, titrate to effect, maximum 20 micrograms/kg/min

-- AND --

nitroprusside: 0.3 to 0.5 micrograms/kg/min intravenously, titrate to effect, maximum 10 micrograms/kg/min

ONGOING

chronic AR: mild to moderate

1st line – reassurance and monitoring

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ONGOING
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chronic AR: mild to moderate
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no indications for other cardiac surgery
1st line – 

reassurance and monitoring

Patients with mild to moderate disease (American College of Cardiology/American Heart Association [ACC/AHA] stage B, progressive AR) who are asymptomatic with normal left ventricular (LV) function do not require treatment and can be reassured.

In these patients, any symptoms or LV dysfunction 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.

1st line – consider concomitant aortic valve surgery

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ONGOING
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chronic AR: mild to moderate
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moderate disease and other cardiac surgery indicated
1st line – 

consider concomitant aortic valve surgery

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

chronic AR: severe, asymptomatic

1st line – reassurance and monitoring

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ONGOING
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chronic AR: severe, asymptomatic
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LVEF >55%, LVESD <50 mm, no indications for other cardiac surgery
1st line – 

reassurance and monitoring

Patients who have asymptomatic AR with left ventricular ejection fraction (LVEF) >55% and LV end-systolic diameter (LVESD) <50 mm (American College of Cardiology/American Heart Association [ACC/AHA] stage C1) require no treatment and the patient can be reassured. Periodic follow-up for symptom and functional status evaluation is recommended.[1]

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

1st line – consider concomitant aortic valve surgery

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ONGOING
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chronic AR: severe, asymptomatic
|
LVEF >55%, LVESD <50 mm, and other cardiac surgery indicated
1st line – 

consider concomitant aortic valve surgery

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

1st line – aortic valve surgery

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ONGOING
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chronic AR: severe, asymptomatic
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LVEF ≤55% and/or LVESD >50 mm, surgical candidate
1st line – 

aortic valve surgery

Aortic valve surgery is indicated in asymptomatic patients with chronic severe AR and left ventricular ejection fraction (LVEF) ≤55% (American College of Cardiology/American Heart Association [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 (LV end-systolic diameter [LVESD] >50 mm or indexed LVESD >25 mm/m²).[1][27]

Aortic valve replacement is performed in most patients requiring surgery. Aortic valve repair is possible in selected patients, but it is only performed in specialist centers. 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.

1st line – aortic valve surgery

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ONGOING
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chronic AR: severe, asymptomatic
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progressive decrease in LVEF (<55% to 60%) or progressive increase in LV end-diastolic diameter (>65 mm), low surgical risk
1st line – 

aortic valve surgery

Surgery can also be considered in patients with chronic severe AR and left ventricular ejection fraction (LVEF) >55% at rest (American College of Cardiology/American Heart Association [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]

Aortic valve replacement is performed in most patients requiring surgery. Aortic valve repair is possible in selected patients, but it is only performed in specialist centers. 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.

1st line – guideline-directed medical therapy (GDMT)

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ONGOING
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chronic AR: severe, asymptomatic
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LVEF ≤55% and/or LVESD >50 mm, nonsurgical candidate
1st line – 

guideline-directed medical therapy (GDMT)

In patients who have severe AR and left ventricular (LV) systolic dysfunction but are at prohibitive surgical risk, GDMT for hypertension and/or reduced LV ejection fraction (LVEF) is recommended.[1]

chronic AR: severe, symptomatic

1st line – aortic valve surgery

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ONGOING
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chronic AR: severe, symptomatic
|
surgical candidate
1st line – 

aortic valve surgery

Aortic valve surgery is indicated in symptomatic patients with chronic severe AR, regardless of systolic function.[1][22][27]

Aortic valve replacement is performed in most patients requiring surgery. Aortic valve repair is possible in selected patients, but it is only performed in specialist centers.

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.

Vasodilators may be used for symptomatic management, while the patient is awaiting surgery.[1]

1st line – guideline-directed medical therapy (GDMT) or transcatheter aortic valve implantation (TAVI)

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ONGOING
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chronic AR: severe, symptomatic
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nonsurgical candidate
1st line – 

guideline-directed medical therapy (GDMT) or transcatheter aortic valve implantation (TAVI)

In symptomatic patients who have severe AR but are at prohibitive surgical risk, GDMT for hypertension and/or reduced left ventricular ejection fraction (LVEF) is recommended.[1]

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]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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