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Editor-In-Chief: C. Michael Gibson, M.S., M.D. ; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D.
Synonyms and keywords: Aortic valve replacement
Aortic valve replacement is indicated in patients with severe aortic insufficiency who are either symptomatic or those who have a left ventricular end-diastolic diameter >55 mm or 25 mm/m2 or an left ventricular ejection fraction <55%.
Indications for Surgery for Chronic Severe Aortic Insufficiency
- Aortic valve replacement improves symptoms in symptomatic patients with severe aortic insufficiency.
- In some studies, the left ventricular function (ejection fraction) also improved following AVR .
- In severe aortic insufficiency, new onset of mild symptoms are also candidates for AVR. Surgery should not be delayed until the development of advanced symptoms as this may result in irreversible left ventricular dysfunction  .
- Patients who are symptomatic with NYHA Class IV heart fialure have poor outcomes following AVR with less likelihood of an improvement in left ventricular systolic function    . Following AVR, ventricular loading conditions may be improved and this may improve the subsequent management of left ventricular dysfunction.
- Symptomatic patients even with mild to moderate left ventricular systolic dysfunction (ejection fraction 25%- 50%) should also undergo AVR.
- The AHA/ACC guidelines recommends that patients with NYHA Class II and III symptoms should undergo valve replacement if :
- Aortic valve replacement/repair is not recommended in a truly asymptomatic patient with normal left ventricular function (left ventricular ejection fraction ≥50%) who does not have severe left ventricular dilatation because this would expose the patient to perioperative mortality risk of 4% against less than 0.2% mortality risk without surgery and other long-term complications of a prosthetic heart valve. In such patients 2006 AHA/ACC guidelines recommends :
- Patients with mild chronic aortic insufficiency with normal left ventricular ejection fraction should undergo clinical evaluation yearly and echocardiography every two to three years.
- Patients with severe chronic aortic insufficiency with normal left ventricular ejection fraction should be followed up based on ventricular dimensions:
- Patients with end-systolic ventricular dimension <45 mm and end-diastolic ventricular dimension <60 mm should undergo clinical evaluation every 6 to 12 months and echocardiography every 12 months. However, if the patient is not stable or if this is the initial study, the patient should be re-evaluated and echocardiography performed in 3 months.
- Patients with end-systolic ventricular dimensions of 45-50 mm and end-diastolic ventricular dimensions of 60-70 mm should undergo clinical evaluation every 6 months and echocardiography every 12 months. However, if the patient is not stable or this is the initial study, then the patient should be re-evaluated and echocardiography performed in 3 months.
- Patients with end-systolic ventricular dimension 50-55 mm and end-diastolic ventricular dimension 70-75 mm with normal hemodynamic response to exercise should undergo clinical evaluation every 6months and echocardiography every 6 months. However, if the patient is not stable or this is the initial study, then the patient should be re-evaluated and echocardiography performed in 3 months.
- When interpreting the cutpoints of left ventricular dimensions, the body size of the patients should also be taken into consideration. Women or patients with small body size may not achieve ventricular dimensions mentioned above as these dimensions were established in men  . On the other hand, body surface area measures are considered in the assessment of left ventricular dimension, tend to mask the diagnosis of left ventricular enlargement, especially in patients who are overweight. Therefore patient's height and gender should be considered during interpretation of ventricular dimensions. 
Indications for surgery for chronic severe aortic insufficiency
|| Ejection fraction
|| Other information
| NYHA class III - IV
|| ≥ 50 %
| NYHA class II
|| ≥ 50 %
|| Progression of symptoms or worsening parameters on echocardiography
| CHA class ≥ II angina
|| ≥ 50 %
| Regardless of symptoms
|| 25 - 49 %
| Cardiac surgery for other cause (ie: CAD, other valvular disease, ascending aortic aneurysm)
2008 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) 
Aortic Valve Replacement Indications (DO NOT EDIT) 
|| * Consider lower threshold values for patients of small stature of either gender.
Aortic Valve Replacement Indications in Adolescents (DO NOT EDIT) 
- 2008 ACC/AHA Guidelines incorporated into the 2006 guidelines for the management of patients with valvular heart disease 
- ↑ Daniel WG, Hood WP, Siart A, Hausmann D, Nellessen U, Oelert H, Lichtlen PR (April 1985). "Chronic aortic regurgitation: reassessment of the prognostic value of preoperative left ventricular end-systolic dimension and fractional shortening". Circulation 71 (4): 669–80. PMID 3156010. Retrieved on 2011-03-27.
- ↑ Carabello BA, Usher BW, Hendrix GH, Assey ME, Crawford FA, Leman RB (November 1987). "Predictors of outcome for aortic valve replacement in patients with aortic regurgitation and left ventricular dysfunction: a change in the measuring stick". Journal of the American College of Cardiology 10 (5): 991–7. PMID 3668112. Retrieved on 2011-03-27.
- ↑ Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB (September 1997). "Optimizing timing of surgical correction in patients with severe aortic regurgitation: role of symptoms". Journal of the American College of Cardiology 30 (3): 746–52. PMID 9283535. Retrieved on 2011-03-27.
- ↑ Carabello BA (July 2004). "Is it ever too late to operate on the patient with valvular heart disease?". Journal of the American College of Cardiology 44 (2): 376–83. doi:10.1016/j.jacc.2004.03.061. PMID 15261934. Retrieved on 2011-03-27.
- ↑ Bonow RO, Dodd JT, Maron BJ, O'Gara PT, White GG, McIntosh CL, Clark RE, Epstein SE (November 1988). "Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation". Circulation 78 (5 Pt 1): 1108–20. PMID 2972417. Retrieved on 2011-03-27.
- ↑ Greves J, Rahimtoola SH, McAnulty JH, DeMots H, Clark DG, Greenberg B, Starr A (March 1981). "Preoperative criteria predictive of late survival following valve replacement for severe aortic regurgitation". American Heart Journal 101 (3): 300–8. PMID 6451163. Retrieved on 2011-03-27.
- ↑ Bonow RO, Picone AL, McIntosh CL, Jones M, Rosing DR, Maron BJ, Lakatos E, Clark RE, Epstein SE (December 1985). "Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: impact of preoperative left ventricular function". Circulation 72 (6): 1244–56. PMID 4064269. Retrieved on 2011-03-27.
- ↑ Cunha CL, Giuliani ER, Fuster V, Seward JB, Brandenburg RO, McGoon DC (February 1980). "Preoperative M-mode echocardiography as a predictor of surgical results in chronic aortic insufficiency". The Journal of Thoracic and Cardiovascular Surgery 79 (2): 256–65. PMID 7351849. Retrieved on 2011-03-27.
- ↑ Clark DG, McAnulty JH, Rahimtoola SH (February 1980). "Valve replacement in aortic insufficiency with left ventricular dysfunction". Circulation 61 (2): 411–21. PMID 7351067. Retrieved on 2011-03-28.
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (October 2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved on 2011-03-28.
- ↑ Bekeredjian R, Grayburn PA (July 2005). "Valvular heart disease: aortic regurgitation". Circulation 112 (1): 125–34. doi:10.1161/CIRCULATIONAHA.104.488825. PMID 15998697. Retrieved on 2011-03-28.
- ↑ Stone PH, Clark RD, Goldschlager N, Selzer A, Cohn K (May 1984). "Determinants of prognosis of patients with aortic regurgitation who undergo aortic valve replacement". Journal of the American College of Cardiology 3 (5): 1118–26. PMID 6707364. Retrieved on 2011-03-28.
- ↑ Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB (November 1996). "Surgery for aortic regurgitation in women. Contrasting indications and outcomes compared with men". Circulation 94 (10): 2472–8. PMID 8921790. Retrieved on 2011-03-28.
- ↑ Mathew RK, Gaasch WH, Guilmette NE, Schick EC, Labib SB (March 2003). "Anthropometric normalization of left ventricular size in chronic mitral regurgitation". The American Journal of Cardiology 91 (6): 762–4. PMID 12633821. Retrieved on 2011-03-28.
- ↑ Vasan RS, Larson MG, Levy D, Evans JC, Benjamin EJ (September 1997). "Distribution and categorization of echocardiographic measurements in relation to reference limits: the Framingham Heart Study: formulation of a height- and sex-specific classification and its prospective validation". Circulation 96 (6): 1863–73. PMID 9323074. Retrieved on 2011-03-28.
- ↑ (1998) "ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease)". J. Am. Coll. Cardiol. 32 (5): 1486–588. PMID 9809971.