Sandbox Rim

Indications for Aortic Valve Replacement

Shown below is an algorithm depicting the indications for aortic valve replacement (AVR) in chronic aortic regurgitation. Patients that fulfill the indications for AVR but have existing comorbidities that do not permit AVR should be treated for hypertension if the blood pressure is more than 140 mmHg.

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

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

AVR (Class I)

AVR (Class I)

AVR (Class I)

AVR (Class IIa)

AVR (Class IIb)

❑ Perform a periodic echocardiogram every 6 - 12 months (Class I, Level of Evidence C) ❑ Control hypertension preferably with ❑ Dihydropyridine CCB, or ❑ ACE inhibitors or ARBs (Class I; Level of Evidence: B)

AVR (Class IIa)

Acute AR

What is the cause of acute AR?

Infective endocarditis

Aortic dissection

Does the patient have AR related heart failure symptoms?

Emergent surgery

Yes

No

Schedule for early aortic valve replacement (Class I, level of evidence B) Click here for more details

Administer antibiotics Follow up the patient Click here for more details