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Indications for Aortic Valve Replacement

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

Abbreviations: LVEF: left ventricular ejection fraction; LVEDD: left ventricular end diastolic diameter; LVESV: left ventricular end systolic diameter

What is the severity of the aortic regurgitation?

Severe regurgitation ❑ Vena contracta >0.6 cm ❑ Doppler jet width ≥ 65% of LVOT ❑ Regurgitant volume ≥60 mL/beat ❑ Regurgitant fraction ≥50% ❑ Effective regurgitant orifice ≥ 0.30 cm² ❑ Holodiastolic flow reversal in the proximal abdominal aorta ❑ Left ventricle dilatation

Progressive regurgitation (Stage B) ❑ Vena contracta <0.6 cm ❑ Regurgitant volume <60 mL/beat ❑ Regurgitant fraction <50% ❑ Effective regurgitant orifice <0.30 cm²

Is the patient symptomatic?

Is the patient undergoing another surgery?

Yes (Stage D)

No (Stage C)

No

Yes

❑ LVEF<50% (Stage C2)

❑ The patient is undergoing another surgery

❑ LVEF ≥ 50% AND ❑ LVESD > 50mm (Stage C2)

❑ LVEF ≥ 50% AND ❑ LVEDD > 65mm AND ❑ Low surgical risk

❑ LVEF ≥ 50% AND ❑ LVESD ≤ 50mm AND ❑ LVEDD ≤ 65mm

Monitor the patient periodically ❑ Control hypertension preferably with ❑ Dihydropyridine CCB, or ❑ ACE inhibitors or ARBs (Class I; Level of Evidence: B) ❑ Perform a periodic echocardiogram (Class I; Level of Evidence:B) ❑ Every 3 -5 years for mild regurgitation ❑ Every 1 - 2 years for moderate regurgitation

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AVR (Class I)

AVR (Class I)

AVR (Class I)

AVR (Class IIa)

AVR (Class IIb)

Monitor the patient periodically

AVR (Class IIa)