Acute aortic regurgitation surgical treatment
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The surgical treatment of choice for aortic insufficiency is aortic valve replacement. This is currently an open-heart procedure, requiring the individual to be placed on cardiopulmonary bypass.
Acute Aortic Insufficiency
In the case of severe acute aortic insufficiency, all individuals should undergo surgery if there are no absolute contraindications for surgery. Individuals with bacteremia with aortic valve endocarditis should not wait for treatment with antibiotics to take effect, given the high mortality associated with the acute aortic insufficiency. Instead, replacement with an aortic valve homograft should be performed if feasible.
Chronic Aortic Insufficiency
Surgical treatment is controversial in asymptomatic patients. Surgery may be recommended if the ejection fraction falls below 50% or in the face of progressive and severe left ventricular dilatation. For both groups of patients, surgery before the development of worse aortic insufficiency ejection fracture/LV systolic dilatation, is expected to reduce the risk of sudden death, and is associated with lower peri-operative mortality.
| Symptoms | 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) | ||
Majority of patients with severe aortic regurgitation requiring surgery undergo aortic valve replacement against aortic valve repair which are preformed at few surgical centers which have appropriate technical expertise and experience in selecting potential patients.
Indications for Aortic valve replacement/Repair(AVR) in Chronic Aortic Insufficiency as per 2006 ACC/AHA Guidelines
| “ | Class I
Class IIa AVR is reasonable for asymptomatic patients with severe aortic insufficiency with normal left ventricular systolic function (ejection fraction greater than 0.50) but with severe left ventricular dilatation (end-diastolic dimension greater than 75 mm or end-systolic dimension greater than 55 mm). Class IIb
Class III AVR is not indicated for asymptomatic patients with mild, moderate, or severe aortic insufficiency and normal left ventricular systolic function at rest (ejection fraction greater than 0.50) when the degree of dilatation is not moderate or severe (end-diastolic dimension less than 70 mm, end-systolic dimension less than 50 mm). |
” |
Surgical corrections of regurgitant aortic valve have shown to improve symptoms in symptomatic patients with severe aortic insufficiency. In some studies, the left ventricular function (ejection fraction) also was seen to improve with AVR[2] [3]. In severe aortic insufficiency, new onset of mild symptoms are also candidates for AVR. It is recommended that surgery should not be delayed till development of advanced symptoms as this may result in development of some degree of irreversible left ventricular dysfunction [4] [5]. Patients who are symptomatic with NYHA Class IV, have poor outcome post AVR with less likelihood of improvement of left ventricular systolic function [6] [7] [8] [9].
Symptomatic patients even with mild to moderate left ventricular systolic dysfunction (ejection fraction 0.25 to 0.50) should also undergo AVR
Severe aortic insufficiency in patient after aortic valve replacement 1
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Severe aortic insufficiency in patient after aortic valve replacement 2
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Severe aortic insufficiency in patient after aortic valve replacement 3
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Severe aortic insufficiency in patient after aortic valve replacement 4
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Severe aortic insufficiency in patient after aortic valve replacement 5
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Severe aortic insufficiency in patient after aortic valve replacement 6
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Severe aortic insufficiency in patient after aortic valve replacement 7
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Severe aortic insufficiency in patient after aortic valve replacement 8
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References
- ↑ "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. 1998. PMID 9809971.
- ↑ Daniel WG, Hood WP, Siart A, Hausmann D, Nellessen U, Oelert H, Lichtlen PR (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 2011-03-27. Unknown parameter
|month=ignored (help) - ↑ Carabello BA, Usher BW, Hendrix GH, Assey ME, Crawford FA, Leman RB (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. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB (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 2011-03-27. Unknown parameter
|month=ignored (help) - ↑ Carabello BA (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 2011-03-27. Unknown parameter
|month=ignored (help) - ↑ Bonow RO, Dodd JT, Maron BJ, O'Gara PT, White GG, McIntosh CL, Clark RE, Epstein SE (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 2011-03-27. Unknown parameter
|month=ignored (help) - ↑ Greves J, Rahimtoola SH, McAnulty JH, DeMots H, Clark DG, Greenberg B, Starr A (1981). "Preoperative criteria predictive of late survival following valve replacement for severe aortic regurgitation". American Heart Journal. 101 (3): 300–8. PMID 6451163. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Bonow RO, Picone AL, McIntosh CL, Jones M, Rosing DR, Maron BJ, Lakatos E, Clark RE, Epstein SE (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 2011-03-27. Unknown parameter
|month=ignored (help) - ↑ Cunha CL, Giuliani ER, Fuster V, Seward JB, Brandenburg RO, McGoon DC (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. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help)