Aortic regurgitation surgery indications
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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: Mohammed A. Sbeih, M.D.[2]; Rim Halaby, M.D. [3]; Usama Talib, BSc, MD [4]; Sabawoon Mirwais, M.B.B.S, M.D.[5]
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.
Most patients with indications for surgery for chronic severe AR require valve replacement with a mechanical or bioprosthetic valve (Figure 4). Preservation of the native aortic valve (“valve sparing”) may be possible in selected patients with favorable valve anatomy who are undergoing surgical replacement of the aortic sinuses and/or ascending aorta.33–39 Although advances are occurring in primary aortic valve repair,37,40–42 this approach is not yet generalizable, and durability is not known. Current recommendations for AVR related to severity of LV dilation are based on measurement of LV short-axis diameters. There are limited data demonstrating prognostic value of LV volume measurements in chronic AR using left ventriculography,43 2D echocardiography,18,44 and CMR.45,46 Normal limits for LV volumes have been determined, as have criteria for severe LV dilation, but these values differ between 2D echocardiography, 3D echocardiography, and CMR,47,48 and there are insufficient data on the relationship between LV volumes and outcomes of patients with AR. This is an area in need of further investigation. Other markers of LV dysfunction and remodeling, such as global longitudinal strain and circulation biomarkers,44,46,49–51 likewise require additional clinical outcome studies.
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 stage C or D AR who are undergoing cardiac surgery for other indications.
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] | |||||||||||||||||||||||||||||
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.
Indications for Surgery for Chronic Aortic Regurgitation
| Management of aortic regurgitation | |||||||||||||||||||||||||||||||||||||||||
| Significant enlargement of ascending aorta | Severe aortic regurgitation | ||||||||||||||||||||||||||||||||||||||||
| Surgery | Symptoms | ||||||||||||||||||||||||||||||||||||||||
| Yes | NO
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| Yes | |||||||||||||||||||||||||||||||||||||||||
| The above algorithm adopted from 2021 ESC Guideline[6] |
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| Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm |
| Severe aortic regurgitation (Class I, Level of Evidence B): |
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❑ Surgery is recommended in symptomatic patients regardless of LV function |
| (Class IIb, Level of Evidence C): |
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❑ 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 |
| (Class I, Level of Evidence C) : |
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❑ 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): |
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❑ Valve-sparing aortic root replacement is recommended in young patients with aortic root dilation |
| (Class I, Level of Evidence C): |
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❑ Ascending aortic surgery is recommended in patients with Marfan syndrome and ascending aortic diameter ≥ 50 mm |
| (Class IIa, Level of Evidence C): |
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❑ 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[6] |
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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[7] |
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- 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%). [8]
- 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.[9] [10]
- 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.[11]
- 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.[12]
- 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.[13]
- TAVI for isolated chronic AR is challenging because of dilation of the aortic annulus and aortic root and lack of sufficient leaflet calcification.[14]
- 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.
References
- ↑ 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.
- ↑ "http://circ.ahajournals.org/content/121/13/e266.full". External link in
|title=(help) - ↑ 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) - ↑ 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) - ↑ 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.
- ↑ 6.0 6.1 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). - ↑ 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). - ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.