Aortic regurgitation surgery indications: Difference between revisions

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'''For the WikiPatient page for this topic, click [[Aortic valve surgery (patient information)|here]]'''; '''For the main page of AR, click [[AR|here]]'''
'''For the WikiPatient page for this topic, click [[Aortic valve surgery (patient information)|here]]'''; '''For the main page of AR, click [[AR|here]]'''


{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]][mailto:msbeih@wikidoc.org]; {{Rim}}; {{USAMA}}; {{sab}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]][mailto:msbeih@wikidoc.org]; {{Rim}}; {{USAMA}}; {{sab}}
{{SK}} 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==
==Overview==
Severe acute [[AR]] requires emergency surgery if there are no absolute contraindications to surgery. The surgery should be performed as early as possible without a delay, particularly if [[hypotension]], decreased [[perfusion]], or [[pulmonary edema]] are present.  In chronic AR, aortic valve replacement (AVR) is indicated in patients with severe AR who are either symptomatic regardless of LV systolic function, or those who are asymptomatic and have left ventricular ejection fraction <55%, or in patients with [[Aortic regurgitation stages|stage C or D]] AR who are undergoing cardiac surgery for other indications.<ref>{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.full.pdf+html | publisher =  | date =  | accessdate = 4 March 2014 }}</ref>
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==
==Indications for Surgery for Acute Aortic Regurgitation==
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===Mild Acute AR in the Setting of Aortic Dissection===
===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]].
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<ref name="pmid33332150">{{cite journal| author=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F | display-authors=etal| title=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. | journal=Circulation | year= 2021 | volume= 143 | issue= 5 | pages= e72-e227 | pmid=33332150 | doi=10.1161/CIR.0000000000000923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332150  }}</ref> ==
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==
==Indications for Surgery for Chronic Aortic Regurgitation==
==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%). <ref name="pmid10199882">{{cite journal |vauthors=Dujardin KS, Enriquez-Sarano M, Schaff HV, Bailey KR, Seward JB, Tajik AJ |title=Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study |journal=Circulation |volume=99 |issue=14 |pages=1851–7 |date=April 1999 |pmid=10199882 |doi=10.1161/01.cir.99.14.1851 |url=}}</ref>
* [[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]].<ref name="pmid7377109">{{cite journal |vauthors=Forman R, Firth BG, Barnard MS |title=Prognostic significance of preoperative left ventricular ejection fraction and valve lesion in patients with aortic valve replacement |journal=Am J Cardiol |volume=45 |issue=6 |pages=1120–5 |date=June 1980 |pmid=7377109 |doi=10.1016/0002-9149(80)90468-3 |url=}}</ref> <ref name="pmid17397676">{{cite journal |vauthors=Bhudia SK, McCarthy PM, Kumpati GS, Helou J, Hoercher KJ, Rajeswaran J, Blackstone EH |title=Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction |journal=J Am Coll Cardiol |volume=49 |issue=13 |pages=1465–71 |date=April 2007 |pmid=17397676 |doi=10.1016/j.jacc.2007.01.026 |url=}}</ref>
* 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.<ref name="pmid3779916">{{cite journal |vauthors=Carabello BA, Williams H, Gash AK, Kent R, Belber D, Maurer A, Siegel J, Blasius K, Spann JF |title=Hemodynamic predictors of outcome in patients undergoing valve replacement |journal=Circulation |volume=74 |issue=6 |pages=1309–16 |date=December 1986 |pmid=3779916 |doi=10.1161/01.cir.74.6.1309 |url=}}</ref>
* 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]].<ref name="pmid2972417">{{cite journal |vauthors=Bonow RO, Dodd JT, Maron BJ, O'Gara PT, White GG, McIntosh CL, Clark RE, Epstein SE |title=Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation |journal=Circulation |volume=78 |issue=5 Pt 1 |pages=1108–20 |date=November 1988 |pmid=2972417 |doi=10.1161/01.cir.78.5.1108 |url=}}</ref>
* [[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]].<ref name="pmid25813142">{{cite journal |vauthors=Zhang Z, Yang J, Yu Y, Huang H, Ye W, Yan W, Shen H, Ii M, Shen Z |title=Preoperative ejection fraction determines early recovery of left ventricular end-diastolic dimension after aortic valve replacement for chronic severe aortic regurgitation |journal=J Surg Res |volume=196 |issue=1 |pages=49–55 |date=June 2015 |pmid=25813142 |doi=10.1016/j.jss.2015.02.069 |url=}}</ref>
*[[TAVI]] for isolated chronic [[AR]] is challenging because of dilation of the [[aortic]] annulus and [[aortic]] root and lack of sufficient leaflet [[calcification]].<ref name="pmid28521923">{{cite journal |vauthors=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 |title=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 |journal=JACC Cardiovasc Interv |volume=10 |issue=10 |pages=1048–1056 |date=May 2017 |pmid=28521923 |doi=10.1016/j.jcin.2017.03.004 |url=}}</ref>
* 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.
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{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
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❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
* >_55 mm in all [[patients]]
* ≥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]])<br>
* ≥45 mm in [[Marfan]] syndrome and additional risk factors or in the presence of [[TGFBR1]] or [[TGFBR2]] mutation (including [[Loeys Dietz syndrome]])<br>
<span style="font-size:85%;color:red">Risk factors<span style="color:red">:</span> family history of aortic dissection (or personal history of spontaneous vascular dissection),<span style="color:red"> </span> severe aortic or mitral regurgitation, <span style="color:red"></span> <span style="color:red"> desire for pregnancy</span>, <span style="color:red">uncontrolled systemic arterial hypertension </span>, <span style="color:red">aortic size increase >3 mm/year </span>
<span style="font-size:85%;color:red">Risk factors<span style="color:red">:</span> family history of aortic dissection (or personal history of spontaneous vascular dissection),<span style="color:red"> </span> severe aortic or mitral regurgitation, <span style="color:red"></span> <span style="color:red"> desire for pregnancy</span>, <span style="color:red">uncontrolled systemic arterial hypertension </span>, <span style="color:red">aortic size increase >3 mm/year </span>
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]]<br>
* ≥ 50 mm in the presence of a [[bicuspid valve]] with additional risk factors or [[coarctation]]<br>
❑ In the presence of primarily indication for the [[surgery]] of [[aortic valve]], replacement of the [[aortic root]] or tubular ascending [[aorta]] should be considered
❑ 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<br>
when ≥ 45 mm<br>
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{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 |  B02= Moderate [[Aortic Regurgitation]]>}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 |  B02= Moderate [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03=Severe [[Aortic Regurgitation]]<br>❑VC>0.6cm<br>❑ [[Holodiastolic aortic flow reversal]]<br>❑ RVol≥60 ml<br>❑ RF≥ 50%<br>❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03= Severe [[Aortic Regurgitation]]<br>❑ VC>0.6cm<br>❑ [[Holodiastolic aortic flow reversal]]<br>❑ RVol≥60 ml<br>❑ RF≥ 50%<br>❑ [[ERO]]≥0.3cm²<br>|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic  (stage D)<br> | C02=Asymptomatic (stage C) <br>|C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])  }}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic  (stage D)<br> | C02=Asymptomatic (stage C) <br>|C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])  }}
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== 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<ref name="pmid333321502">{{cite journal| author=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F | display-authors=etal| title=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. | journal=Circulation | year= 2021 | volume= 143 | issue= 5 | pages= e72-e227 | pmid=33332150 | doi=10.1161/CIR.0000000000000923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332150  }}</ref> ==


Symptoms are an important indication for AVR in patients with chronic severe AR, and the most important aspect of the clinical evaluation is taking a careful, detailed history to elicit symptoms or diminution of exercise capacity. Patients with chronic severe AR who develop symptoms have a high risk of death if AVR is not performed,52 and survival and functional status after AVR are related to the severity of preoperative symptoms, assessed either subjectively or objectively with exercise testing.1–4 Even among symptomatic patients with a severe reduction in LVEF (<35%), AVR results in improved survival rate.5–7
=== Recommendations for Timing of Intervention for Chronic AR Referenced studies that support the recommendations are summarized in The Online Data Supplement  ===
2.
{| class="wikitable"
LV systolic function is an important determinant of survival and functional status after AVR.3–5,8,9,12,53–61 Outcomes are optimal when surgery is performed before LVEF decreases below 55%.16,25,26 In asymptomatic patients with LV systolic dysfunction, postoperative outcomes are better if AVR is performed before onset of symptoms.53
|-
3.
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
Patients with chronic severe AR may be referred for other types of cardiac surgery, such as CABG, mitral valve surgery, or surgery for correction of dilation of the aortic root or ascending aorta. In these patients, AVR will prevent both the hemodynamic consequences of persistent AR during the perioperative period and the possible need for a second cardiac operation in the near future. Patients undergoing surgical repair or replacement of the aortic root or ascending aorta may be candidates for aortic valve–sparing procedures.33–39
|-
4.
| bgcolor="LightGreen" |1.   In symptomatic patients with severe AR (Stage D), aortic valve surgery is indicated regardless of LV systolic function''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR)]]''
LVESD in patients with chronic AR reflects both the severity of the LV volume overload and the degree of LV systolic shortening.54,62 An elevated LVESD often reflects LV systolic dysfunction with a depressed LVEF. If LVEF is normal, an increased LVESD indicates a significant degree of LV remodeling and is associated with subsequent development of symptoms and/or LV systolic dysfunction and an increased mortality rate after AVR.17,20,21 Most studies have used unadjusted LVESD, but indexing for body size is important, particularly in women or small patients.13,19,52 Recent data indicate that the LVESD index threshold for optimal postoperative survival may be even smaller than 25 mm/m2,14–16 but more outcome data, and ideally an RCT, of earlier intervention are needed. LV volumes may be a more sensitive predictor of cardiac events than LVESD index in asymptomatic patients,18 but more data are needed to determine the threshold values of LV systolic volume that best predict postoperative outcomes.
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''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR)]]''
5.
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, the decision to intervene on the aortic valve concurrently includes consideration of several factors, including aortic valve anatomy, aortic root size and shape, regurgitant severity, other comorbidities, and patients’ preferences and values. Patients undergoing surgical repair or replacement of the aortic root or ascending aorta may be candidates for a valve-sparing procedure.33–39
6.
LVEDD, a marker of the severity of LV volume overload in patients with chronic AR, is significantly associated with clinical outcomes in asymptomatic patients, and progressive increases in LVEDD are associated with subsequent need for surgery.16,17,20,25–28 In asymptomatic patients, it is important to ensure that apparent changes in LV size or LVEF are not due simply to measurement or physiological variability. In addition, confirmation of severe regurgitation by quantitative measures of AR severity with TTE, TEE, or, when needed, CMR provides confidence that AR is the cause of LV dilation or decrease in LVEF. When there is an apparent significant fall in EF or increase in LV size, repeat imaging typically is performed at 3- to 6-month intervals unless there is clinical deterioration.
7.
TAVI for isolated chronic AR is challenging because of dilation of the aortic annulus and aortic root and, in many patients, lack of sufficient leaflet calcification. Risks of TAVI for treatment of AR include transcatheter valve migration and significant paravalvular leak.29–32 TAVI is rarely feasible, and then only in carefully selected patients with severe AR and HF who have a prohibitive surgical risk and in whom valvular calcification and annular size are appropriate for a transcatheter approach.


3.   In patients with severe AR (Stage C or D) who are undergoing cardiac surgery for other indications, aortic valve surgery is indicated.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
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{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |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)''([[ACC AHA guidelines classification scheme#Level of Evidence|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.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
|}


 
{| class="wikitable"
Shown below is an algorithm depicting the indications for [[aortic valve replacement]] ([[AVR]]) in chronic aortic regurgitation.
|-
 
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
*The AHA/ACC guidelines recommends that patients undergo AVR in the following cases:<ref>{{Cite web  | last = | first = | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.full.pdf+html | publisher =  | date =  | accessdate = 4 March 2014 }}</ref>
|-
** Stage D: presence of symptoms with severe AR regardless of LV systolic function
| bgcolor="LemonChiffon" |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)''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR)]]''
** Stage C2: absence of symptoms with chronic severe AR + LV systolic dysfunction (LVEF <50%)
|}
** Stage C or D AR in a patient undergoing cardiac surgery for other indications
 
 
 
 
 
 
 
 
 
 
 
*The AHA/ACC guidelines considers AVR reasonable in the following cases:<ref>{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.full.pdf+html | publisher =  | date =  | accessdate = 4 March 2014 }}</ref>
** Stage C2: absence of symptoms with severe AR + normal [[LV]] systolic function (LVEF ≥50%) + severe LV dilation (LVESD >50 mm)
** Stage B: moderate AR in a patient undergoing cardiac surgery for other indications
** Stage C1: absence of symptoms with severe AR + normal [[LV]] systolic function (LVEF ≥50%)+ progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low
 
*Aortic valve replacement/repair is not recommended in a truly asymptomatic patient with normal left ventricular function (left ventricular [[ejection fraction]] ≥50%) who does not have severe left ventricular dilatation because this would expose the patient to perioperative mortality risk of 4% against less than 0.2% mortality risk without surgery and other long-term complications of a [[prosthetic heart valve]].<ref name="pmid15998697">{{cite journal |author=Bekeredjian R, Grayburn PA |title=Valvular heart disease: aortic regurgitation |journal=[[Circulation]] |volume=112 |issue=1 |pages=125–34 |year=2005 |month=July |pmid=15998697 |doi=10.1161/CIRCULATIONAHA.104.488825 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15998697 |accessdate=2011-03-28}}</ref>
 
*In severe AR, new onset of mild symptoms are also candidates for AVR. Surgery should not be delayed until the development of advanced symptoms as this may result in irreversible left ventricular dysfunction.<ref name="pmid9283535">{{cite journal |author=Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB |title=Optimizing timing of surgical correction in patients with severe aortic regurgitation: role of symptoms |journal=[[Journal of the American College of Cardiology]] |volume=30 |issue=3 |pages=746–52 |year=1997 |month=September |pmid=9283535 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(97)00205-2 |accessdate=2011-03-27}}</ref> <ref name="pmid15261934">{{cite journal |author=Carabello BA |title=Is it ever too late to operate on the patient with valvular heart disease? |journal=[[Journal of the American College of Cardiology]] |volume=44 |issue=2 |pages=376–83 |year=2004 |month=July |pmid=15261934 |doi=10.1016/j.jacc.2004.03.061 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109704007958 |accessdate=2011-03-27}}</ref>
 
*Aortic valve replacement improves symptoms in symptomatic patients with severe AR.  In some studies, the left ventricular function ([[ejection fraction]]) also improved following AVR.<ref name="pmid3156010">{{cite journal |author=Daniel WG, Hood WP, Siart A, Hausmann D, Nellessen U, Oelert H, Lichtlen PR |title=Chronic aortic regurgitation: reassessment of the prognostic value of preoperative left ventricular end-systolic dimension and fractional shortening |journal=[[Circulation]] |volume=71 |issue=4 |pages=669–80 |year=1985 |month=April |pmid=3156010 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=3156010 |accessdate=2011-03-27}}</ref> <ref name="pmid3668112">{{cite journal |author=Carabello BA, Usher BW, Hendrix GH, Assey ME, Crawford FA, Leman RB |title=Predictors of outcome for aortic valve replacement in patients with aortic regurgitation and left ventricular dysfunction: a change in the measuring stick |journal=[[Journal of the American College of Cardiology]] |volume=10 |issue=5 |pages=991–7 |year=1987 |month=November |pmid=3668112 |doi= |url= |accessdate=2011-03-27}}</ref>  Patients who are symptomatic with [[NYHA]] Class IV heart failure have poor outcomes following AVR with less likelihood of an improvement in left ventricular systolic function.<ref name="pmid2972417">{{cite journal |author=Bonow RO, Dodd JT, Maron BJ, O'Gara PT, White GG, McIntosh CL, Clark RE, Epstein SE |title=Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation |journal=[[Circulation]] |volume=78 |issue=5 Pt 1 |pages=1108–20 |year=1988 |month=November |pmid=2972417 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=2972417 |accessdate=2011-03-27}}</ref> <ref name="pmid6451163">{{cite journal |author=Greves J, Rahimtoola SH, McAnulty JH, DeMots H, Clark DG, Greenberg B, Starr A |title=Preoperative criteria predictive of late survival following valve replacement for severe aortic regurgitation |journal=[[American Heart Journal]] |volume=101 |issue=3 |pages=300–8 |year=1981 |month=March |pmid=6451163 |doi= |url= |accessdate=2011-03-27}}</ref> <ref name="pmid4064269">{{cite journal |author=Bonow RO, Picone AL, McIntosh CL, Jones M, Rosing DR, Maron BJ, Lakatos E, Clark RE, Epstein SE |title=Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: impact of preoperative left ventricular function |journal=[[Circulation]] |volume=72 |issue=6 |pages=1244–56 |year=1985 |month=December |pmid=4064269 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=4064269 |accessdate=2011-03-27}}</ref> <ref name="pmid7351849">{{cite journal |author=Cunha CL, Giuliani ER, Fuster V, Seward JB, Brandenburg RO, McGoon DC |title=Preoperative M-mode echocardiography as a predictor of surgical results in chronic AR |journal=[[The Journal of Thoracic and Cardiovascular Surgery]] |volume=79 |issue=2 |pages=256–65 |year=1980 |month=February |pmid=7351849 |doi= |url= |accessdate=2011-03-27}}</ref> Following AVR, ventricular loading conditions may be improved and this may improve the subsequent management of [[left ventricular dysfunction]].<ref name="pmid7351067">{{cite journal |author=Clark DG, McAnulty JH, Rahimtoola SH |title=Valve replacement in AR with left ventricular dysfunction |journal=[[Circulation]] |volume=61 |issue=2 |pages=411–21 |year=1980 |month=February |pmid=7351067 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7351067 |accessdate=2011-03-28}}</ref>
 
*When interpreting the cutpoints of left ventricular dimensions, the body size of the patients should also be taken into consideration.  Women or patients with small body size may not achieve ventricular dimensions mentioned above as these dimensions were established in men.<ref name="pmid6707364">{{cite journal |author=Stone PH, Clark RD, Goldschlager N, Selzer A, Cohn K |title=Determinants of prognosis of patients with aortic regurgitation who undergo aortic valve replacement |journal=[[Journal of the American College of Cardiology]] |volume=3 |issue=5 |pages=1118–26 |year=1984 |month=May |pmid=6707364 |doi= |url= |accessdate=2011-03-28}}</ref> <ref name="pmid8921790">{{cite journal |author=Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB |title=Surgery for aortic regurgitation in women. Contrasting indications and outcomes compared with men |journal=[[Circulation]] |volume=94 |issue=10 |pages=2472–8 |year=1996 |month=November |pmid=8921790 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8921790 |accessdate=2011-03-28}}</ref> On the other hand, body surface area measures are considered in the assessment of left ventricular dimension, tend to mask the diagnosis of left ventricular enlargement, especially in patients who are overweight.<ref name="pmid12633821">{{cite journal |author=Mathew RK, Gaasch WH, Guilmette NE, Schick EC, Labib SB |title=Anthropometric normalization of left ventricular size in chronic mitral regurgitation |journal=[[The American Journal of Cardiology]] |volume=91 |issue=6 |pages=762–4 |year=2003 |month=March |pmid=12633821 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914902034276 |accessdate=2011-03-28}}</ref> Therefore patient's height and gender should be considered during interpretation of ventricular dimensions.<ref name="pmid9323074">{{cite journal |author=Vasan RS, Larson MG, Levy D, Evans JC, Benjamin EJ |title=Distribution and categorization of echocardiographic measurements in relation to reference limits: the Framingham Heart Study: formulation of a height- and sex-specific classification and its prospective validation |journal=[[Circulation]] |volume=96 |issue=6 |pages=1863–73 |year=1997 |month=September |pmid=9323074 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=9323074 |accessdate=2011-03-28}}</ref>
 
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Latest revision as of 13:48, 8 December 2022
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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.[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)
    4. ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (2008). "2008 Focused update incorporated into the ACC/AHA 2006 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved 2011-04-07. Unknown parameter |month= ignored (help)
    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).
    7. ↑ Dujardin KS, Enriquez-Sarano M, Schaff HV, Bailey KR, Seward JB, Tajik AJ (April 1999). "Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study". Circulation. 99 (14): 1851–7. doi:10.1161/01.cir.99.14.1851. PMID 10199882.
    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).
    15. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help).
    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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