Aortic regurgitation surgery indications

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Aortic Insufficiency Surgery
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For the WikiPatient page for this topic, click here; For the main page of AR, click here

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.

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 ❑ Administer beta blockers with caution (beta blockers inhibit compensatory tachycardia)

Yes

No

❑ Schedule for early aortic valve replacement (Class I, level of evidence B)

❑ Administer antibiotics ❑ 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. Intra-aortic balloon pump is contraindicated as this would worsen aortic regurgitation by increasing afterload due to the inflation of the balloon during diastole.

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

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.

Notes

• Symptoms is an important indication for AVR in patients with chronic severe AR.
• Taking a careful, detailed history regarding symptoms or reduced exercise capacity is important.
• AVR results in an improved survival rate even among symptomatic patients with a severe reduction in LVEF (<35%).
• LV systolic function is an important determinant of survival and functional status after AVR.
• Optimal outcome reaches when AVR is performed before LVEF decreases below 55% or before the onset of symptoms.
• Other types of cardiac surgery, such as CABG, mitral valve surgery, or surgery for correction of dilation of the aortic root or ascending aorta can be performed at the time of AVR.
• LVESD in patients with chronic AR indicates both the severity of the LV volume overload and the degree of LV systolic shortening.
• An elevated LVESD shows LV systolic dysfunction with a depressed LVEF. If LVEF is normal, increased LVESD indicates a significant degree of LV remodeling resulting development of symptoms and/or LV systolic dysfunction and an increased mortality rate after AVR.
• Body size index is important, especially in women or small patients.
• LV volumes may be a more sensitive predictor of cardiac events than LVESD index in asymptomatic patients.
• In patients with moderate AR who are undergoing other forms of cardiac surgery, such as CABG, mitral valve surgery, or replacement of the ascending aorta, consideration of aortic valve anatomy, aortic root size and shape, regurgitant severity, other comorbidities, and patient's preferences and values is recommended.
• Valve-sparing procedure may be considered in patients undergoing surgical repair or replacement of the aortic root or ascending aorta.
• In asymptomatic patients with chronic AR, LVEDD is a marker of the severity of LV volume overload and associated with clinical outcomes , and progressive increases in LVEDD are associated with a further need for surgery.
• TAVI for isolated chronic AR is challenging because of dilation of the aortic annulus and aortic root and lack of sufficient leaflet calcification.
• Risks of TAVI for treatment of AR include transcatheter valve migration and significant paravalvular leak.
• TAVI is rarely feasible, and transcatheter approach may be performed in the selected patients with severe AR and HF, high surgical risk , with valvular calcification and appropriate annular size.

Management of aortic regurgitation

Significant enlargement of ascending aorta

Severe aortic regurgitation

Surgery

Symptoms

Yes Surgery

NO LVEF≤ 50% or LVESD > 50 mm (or > 25 mm/m2 BSA)

Yes Surgery

The above algorithm adopted from 2021 ESC Guideline

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: ≥55 mm in all patients ≥45 mm in Marfan syndrome and additional risk factors or in the presence of TGFBR1 or TGFBR2 mutation (including Loeys Dietz syndrome) 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 ≥ 50 mm in the presence of a bicuspid valve with additional risk factors or coarctation ❑ 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

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

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

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)