Aortic regurgitation surgery indications

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Mohammed A. Sbeih, M.D.[3]; Rim Halaby, M.D. [4]; Usama Talib, BSc, MD [5]; Sabawoon Mirwais, M.B.B.S, M.D.[6] Synonyms and keywords: AR; Aortic Regurgitation; AVR; Aortic Valve Replacement;LVESD; Left Ventricular End Systolic Diameter;LV; Left Ventricle;LVEF;Left Ventricular Ejection Fraction;CABG;Coronart Artery Bypass Grafting;LVEDD; Left Vntricular End Diastolic Diameter;TAVI; Transcatheter Aortic Valve Replacement

Overview

Severe acute AR requires emergency surgery. The surgery should be performed as early as possible without a delay, particularly if hypotension, decreased perfusion, or pulmonary edema are present. In patients with chronic severe AR, mechanical or bioprosthetic valve may be used for valve surgery. In patients undergoing surgical replacement of the aortic sinuses and/or ascending aorta, maintaining of the native aortic valve (valve-sparing) may be possible in selected patients with favorable valve anatomy. Primary aortic valve repair is not yet generalizable, and durability is not known. AVR is recommended when there is LV dilation based on the measurement of LV in short-axis diameters. There are insufficient data on the relationship between LV volumes and outcomes of patients with AR.

Indications for Surgery for Acute Aortic Regurgitation

Timing of Emergency Surgery

Acute severe AR may cause death due to pulmonary edema, ventricular arrhythmias, electromechanical dissociation, or circulatory collapse. Individuals with bacteremia with aortic valve endocarditis should not wait for treatment with antibiotics to take effect, especially if there is hypotension, pulmonary edema, or low cardiac output given the high mortality associated with the acute AR.

Shown below is an algorithm for the treatment of acute AR.[1]

Abbreviations: AVR: Aortic valve replacement; ACE: Angiotensin converting enzyme; ARB: Angiotensin receptor blocker; CCB: Calcium channel blocker; LVEF: Left ventricle ejection fraction; TTE: Transthoracic echocardiography

 
 
 
 
What is the cause of acute AR?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infective endocarditis
 
Aortic dissection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have AR related heart failure symptoms?
 
❑ Schedule for an emergent surgery[2]
❑ Administer beta blockers with caution (beta blockers inhibit compensatory tachycardia)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Schedule for early aortic valve replacement (Class I, level of evidence B)[3]
 
❑ Administer antibiotics[3]
❑ Follow up the patient
 
 
 

Type of Surgery

Replacement with an aortic valve homograft should be performed if feasible. The surgical approach depends upon the cause of AR. Aortic valve replacement or repair may be needed in cases of valvular structural abnormalities and aortic root repair/replacement may be needed in cases of aortic dissection.

Preoperative Medical Therapy

Patients may be temporarily managed before surgery with vasodilators such as nitroprusside and possibly inotropic agents such as dopamine or dobutamine to improve stroke volume and reduce left ventricular end-diastolic pressure.[4] Intra-aortic balloon pump is contraindicated as this would worsen aortic regurgitation by increasing afterload due to the inflation of the balloon during diastole.[5]

Mild Acute AR in the Setting of Aortic Dissection

In mild AR secondary to aortic dissection, the aortic valve can be repaired/replaced at the time of surgery for aortic dissection.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[6]

Medical treatment to lower LV afterload may temporarily stabilize patients with acute severe AR brought on by IE or aortic dissection, but surgery should not be postponed, especially if there is hypotension, pulmonary edema, or indications of low flow. 1-4 In individuals with acute severe AR, intra-aortic balloon counterpulsation is not recommended.

Indications for Surgery for Chronic Aortic Regurgitation

Notes








 
 
 
Management of aortic regurgitation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Significant enlargement of ascending aorta
 
 
 
Severe aortic regurgitation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery
 
 
 
Symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
NO
  • LVEF≤ 50% or
  • LVESD > 50 mm (or > 25 mm/m2 BSA)
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     


    The above algorithm adopted from 2021 ESC Guideline[14]



    Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm
    Severe aortic regurgitation (Class I, Level of Evidence B):

    Surgery is recommended in symptomatic patients regardless of LV function
    Surgery is recommended in asymptomatic patients with LVESD > 50 mm or LVESD > 25 mm/m2 BSA (in patients with small body size) or resting LVEF ≤ 50%

    (Class IIb, Level of Evidence C):

    Surgery may be considered in asymptomatic patients with LVESD >20 mm/m2 BSA (especially in patients with small body size) or resting LVEF ≤ 55%, in low risk condition
    ❑Aortic valve repair may be considered in selected patients at experienced centres when durable results are expected

    (Class I, Level of Evidence C) :

    Surgery is recommended in symptomatic and asymptomatic patients with severe aortic regurgitation undergoing CABG or surgery of the ascending aorta or of another valve

    Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation (Class I, Level of Evidence B):

    Valve-sparing aortic root replacement is recommended in young patients with aortic root dilation

    (Class I, Level of Evidence C):

    ❑ Ascending aortic surgery is recommended in patients with Marfan syndrome and ascending aortic diameter ≥ 50 mm

    (Class IIa, Level of Evidence C):

    ❑ Ascending aortic surgery is recommended with ascending aorta size of:

    Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year

    ❑ In the presence of primarily indication for the surgery of aortic valve, replacement of the aortic root or tubular ascending aorta should be considered when ≥ 45 mm

    Abbreviations: BSA: Body surface area; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; LVESV:Left ventricular end-systolic diamete



    The above table adopted from 2021 ESC Guideline[14]







    Shown below is an algorithm depicting the indications for aortic valve replacement (AVR) in chronic aortic regurgitation.

     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Aortic Regurgitation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Moderate Aortic Regurgitation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Severe Aortic Regurgitation
    ❑ VC>0.6cm
    Holodiastolic aortic flow reversal
    ❑ RVol≥60 ml
    ❑ RF≥ 50%
    ERO≥0.3cm²
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Other cardiac surgery
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Symptomatic (stage D)
     
     
     
     
     
     
     
     
     
    Asymptomatic (stage C)
     
     
     
     
     
     
     
     
     
     
     
    AVR (Class IIa)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    LVEF≤ 55% (stage C2)
     
     
     
     
     
    ❑ Other cardiac surgerysurgery
     
    LVEF> 55%
    AND
    LVESD > 50mm (LVESD>25mm/m²
    )
     
    ❑ Progressive decrese in LVEF to <55%-60% or increase in LVEDD to >65mm on at least 3 studies
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    AVR (Class I)
     
    AVR (Class I)
     
     
     
     
     
    AVR (Class I)
     
    AVR (Class IIa)
     
    Low surgical risk
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    AVR (Class IIb)
     

    Abbreviations: LVEF: left ventricular ejection fraction; LVEDD: left ventricular end diastolic diameter; LVESV: left ventricular end systolic diameter; VC: vena contracta; RVol: regurgitant volume; RF: regurgitant fraction; ERO: effective regurgitant orifice

    The above algorithm adopted from 2020 AHA Guideline[15]

    2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[16]

    Recommendations for Timing of Intervention for Chronic AR Referenced studies that support the recommendations are summarized in The Online Data Supplement

    Class I
    1.   In symptomatic patients with severe AR (Stage D), aortic valve surgery is indicated regardless of LV systolic function(Level of Evidence: B-NR)

    2.   In asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF ≤55%) (Stage C2), aortic valve surgery is indicated if no other cause for systolic dysfunction is identified(Level of Evidence: B-NR)

    3.   In patients with severe AR (Stage C or D) who are undergoing cardiac surgery for other indications, aortic valve surgery is indicated.(Level of Evidence: C-EO)


    Class IIa
    4.   In asymptomatic patients with severe AR and normal LV systolic function (LVEF >55%), aortic valve surgery is reasonable when the LV is severely enlarged (LVESD >50 mm or indexed LVESD >25 mm/m2) (Stage C2)(Level of Evidence: B-NR)

    5.   In patients with moderate AR (Stage B) who are undergoing cardiac or aortic surgery for other indications, aortic valve surgery is reasonable.(Level of Evidence: C-EO)

    Class IIb
    6.   In asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF >55%; Stage C1) and low surgical risk, aortic valve surgery may be considered when there is a progressive decline in LVEF on at least 3 serial studies to the low–normal range (LVEF 55% to 60%) or a progressive increase in LV dilation into the severe range (LV end-diastolic dimension [LVEDD] >65 mm)(Level of Evidence: B-NR)

    References

    1. Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). "2014 AHA/ACC Guideline 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". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.
    2. "http://circ.ahajournals.org/content/121/13/e266.full". External link in |title= (help)
    3. 3.0 3.1 Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)
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    5. Rius JB, Mercè AS, del Blanco BG, Aguasca GM, Mas PT, García-Dorado García D (2011). "Resolution of shock-induced aortic regurgitation with an intraaortic balloon pump". Circulation. 124 (4): e131. doi:10.1161/CIRCULATIONAHA.111.038653. PMID 21788594.
    6. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).
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    8. Forman R, Firth BG, Barnard MS (June 1980). "Prognostic significance of preoperative left ventricular ejection fraction and valve lesion in patients with aortic valve replacement". Am J Cardiol. 45 (6): 1120–5. doi:10.1016/0002-9149(80)90468-3. PMID 7377109.
    9. Bhudia SK, McCarthy PM, Kumpati GS, Helou J, Hoercher KJ, Rajeswaran J, Blackstone EH (April 2007). "Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction". J Am Coll Cardiol. 49 (13): 1465–71. doi:10.1016/j.jacc.2007.01.026. PMID 17397676.
    10. Carabello BA, Williams H, Gash AK, Kent R, Belber D, Maurer A, Siegel J, Blasius K, Spann JF (December 1986). "Hemodynamic predictors of outcome in patients undergoing valve replacement". Circulation. 74 (6): 1309–16. doi:10.1161/01.cir.74.6.1309. PMID 3779916.
    11. 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. doi:10.1161/01.cir.78.5.1108. PMID 2972417.
    12. Zhang Z, Yang J, Yu Y, Huang H, Ye W, Yan W, Shen H, Ii M, Shen Z (June 2015). "Preoperative ejection fraction determines early recovery of left ventricular end-diastolic dimension after aortic valve replacement for chronic severe aortic regurgitation". J Surg Res. 196 (1): 49–55. doi:10.1016/j.jss.2015.02.069. PMID 25813142.
    13. Sawaya FJ, Deutsch MA, Seiffert M, Yoon SH, Codner P, Wickramarachchi U, Latib A, Petronio AS, Rodés-Cabau J, Taramasso M, Spaziano M, Bosmans J, Biasco L, Mylotte D, Savontaus M, Gheeraert P, Chan J, Jørgensen TH, Sievert H, Mocetti M, Lefèvre T, Maisano F, Mangieri A, Hildick-Smith D, Kornowski R, Makkar R, Bleiziffer S, Søndergaard L, De Backer O (May 2017). "Safety and Efficacy of Transcatheter Aortic Valve Replacement in the Treatment of Pure Aortic Regurgitation in Native Valves and Failing Surgical Bioprostheses: Results From an International Registry Study". JACC Cardiovasc Interv. 10 (10): 1048–1056. doi:10.1016/j.jcin.2017.03.004. PMID 28521923.
    14. 14.0 14.1 Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
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    16. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).

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