Current Management of Patients with Severe Aortic Regurgitation

Abstract

Chronic aortic regurgitation can result from various congenital and acquired anomalies and can be associated with proximal aortic disease. As the number of aortic valve procedures is growing, the incidence of post-procedural regurgitation also increases with associated morbidity. Typical evolution is characterized by a clinically silent phase of variable duration followed by a rather rapid decline with high incidence of adverse events. A challenge remains to find the optimal timing for an intervention: Patients are exposed to unnecessary surgical risks if treated prematurely, but peri- and post-operative prognosis is worse when the intervention is performed too late. Clinical evaluation and serial imaging tests can optimize the timing for intervention. Clinical follow-up should try to elucidate associated symptoms, with quantitative measurement of functional capacity as needed. Serial imaging examinations are required to identify sub-clinical left ventricular dysfunction or severe dilatation that should prompt a surgery. At least in selected cases, newer imaging modalities (MRI, 3D echocardiography) and/or biomarkers can help for the management of these patients, and more research is needed to determine if their systematic use can be beneficial. Medical treatment with vasodilators and anti-remodeling drugs can be helpful in some patients but should not replace or delay aortic valve surgery when indicated. Most patients will eventually be treated with surgical aortic valve replacement. Although possible in selected cases, transcatheter aortic valve replacement is not commonly used for patients with pure aortic regurgitation. For patients with prior aortic valve replacement and aortic regurgitation (paravalvular or intravalvular), emerging percutaneous approaches can be considered when available, especially for those at high surgical risk.

The predictive value of left ventricular myocardium mechanics evaluation in asymptomatic patients with aortic regurgitation and preserved left ventricular ejection fraction. A long‐term speckle‐tracking echocardiographic study

“…33 Guideline recommendations for surgery in asymptomatic patients with AR have focused on LVEF and LV end-systolic and end-diastolic dimensions. 33 Guideline recommendations for surgery in asymptomatic patients with AR have focused on LVEF and LV end-systolic and end-diastolic dimensions.…”

“…Chronic aortic regurgitation is an insidious disease, the typical evolution of which is characterized by a clinically silent phase of variable duration followed by a relatively rapid decline with the high incidence of adverse events. 32,33 These events are furthermore related to detrimental structural changes in the myocardium, such as fibrosis, which impact the worse prognosis. 7,34,35 The current management of asymptomatic patients with severe AR and preserved LVEF is based on the serial testing of echocardiographic parameters, such culation of myocardium strain obtained by STE has been introduced a more objective and quantitative method of quantifying regional and global LV function due to its direct measurement of myocardial deformation.…”

“…A major clinical challenge is to find the transition point where the prognosis of asymptomatic severe AR starts to carry more risk than that associated with aortic valve surgery itself. 33 Guideline recommendations for surgery in asymptomatic patients with AR have focused on LVEF and LV end-systolic and end-diastolic dimensions. 2,4 However, making decisions about aortic valve surgery on the basis of LVEF and LV internal dimensions is frequently problematic given the inherent variability of these measurements.…”

Aortic valvular imaging with cardiovascular magnetic resonance: seeking for comprehensiveness

“…63 Based on CMR parameter AR may be classified into mild (RF <20%), moderate (RF: 20-29%, ARO: 0.3-0.5 cm 2 ) and severe (RF ≥30%, ARO ≥ 0.5 cm 2 ), when PC-MRI images are acquired at the sino-tubular junction. 64 However, there is no unanimous consensus about the optimal threshold for classifying severe AR by CMR, as other studies demonstrated that a value above 33% strongly predicted the need of surgery in 3 years, similarly to the value of 50% used in echocardiography. 28,65 Severe AR is also considered severe in case of reduced LV function parameters (LVEF <50 %, LV end-diastolic dimension ≤70 mm, LV end-systolic dimension ≤50 mm, and indexed LV end-systolic dimension <25 mm/m).…”

“…2,4 Compared to linear measurements, LV volumes measured by CMR seems to better predict survival and outcome. 65 Assessment of LV end-diastolic and end-systolic volumes indexed for body surface area should be obtained serially, 64 because even in asymptomatic patients with normal LV function, LV progressive dilatation is a reasonable indication for surgery. 4 Considering the importance of annual follow-up in patients with mild to severe AR, in order to estimate the progression of the disease, it is important not to classify chronic regurgitation as severe only on the basis of a single TTE or CMR.…”