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Risk Stratification: Timing of Surgery and Percutaneous Interventions for Aortic Regurgitation
Aortic regurgitation (AR) may lead to serious morbidity and excess mortality. As noted in the preceding chapters, the diagnosis of AR should be based on the guidelines for native valvular regurgitation by the American Society of Echocardiography and other international organizations. , The role of medical, percutaneous, and surgical options for the treatment of AR is discussed in this chapter. The recommendations for AR treatment follow the latest joint American Heart Association (AHA) and American College of Cardiology (ACC) valvular heart disease guidelines. Surgery remains the only definitive means of treating AR in appropriate patients. There is a fundamental difference between acute and chronic AR. Acute severe AR is a medical emergency that rapidly progresses from an asymptomatic to a symptomatic stage resulting in severe heart failure. In contrast, chronic AR progresses through four stages (A–D) as described in 2014 ACC/AHA guidelines ( Table 89.1 ).
TABLE 89.1
Staging of Chronic Aortic Regurgitation According to the 2014 American College of Cardiology/American Heart Association Guidelines
| Patients With Aortic Regurgitation | Class of Recommendation | Level of Evidence |
|---|---|---|
| Symptomatic Severe AR | I | B |
| Asymptomatic Severe AR | ||
| LVEF <50% | I | B |
| LVESD >50 mm or indexed LVESD >25 mm/m 2 | IIa | B |
| LVEDD >65 mm and low surgical risk | IIb | C |
| Undergoing other cardiac surgery | I | C |
| Severe AR | I | C |
| Moderate AR | IIa | C |
AR, Aortic regurgitation; LVEDD, left ventricular end-diastolic diameter; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter.
Medical Therapy
No medical therapy has been shown to alter the natural progression or to improve survival in patients with AR. The role of medical therapy is primarily to alleviate the symptoms and to treat associated conditions such as systemic hypertension and heart failure.
Acute Aortic Regurgitation
There are limited medical management options for patients with acute AR. Surgical aortic valve replacement (AVR) remains the primary form of treatment. β-Blockers are used in the treatment of AR associated with type A aortic dissection. When acute AR is associated with other causes, β-blockers should be used with caution, if at all, because their use prevents compensatory tachycardia and may lead to hypotension. In hemodynamically unstable patients with acute AR, intravenous (IV) arterial dilators can be used to decrease afterload and improve forward flow. IV diuretics may be given to relieve congestion. If the patient is in cardiogenic shock, then IV inodilators, such as dobutamine, may be used.
Chronic Aortic Regurgitation
In chronic severe AR, there is no proven disease-modifying medical therapy. Systolic hypertension (systolic blood pressure >140 mm Hg) in patients with chronic AR should preferably be treated with vasodilators (dihydropyridine calcium channel blockers, angiotensin-converting enzyme [ACE] inhibitors, and/or angiotensin receptor blockers [ARBs]). If the left ventricular ejection fraction (LVEF) is diminished, the used of β-blockers, ACE inhibitors, and/or ARBs is recommended. In contrast, vasodilator therapy has not been shown to be beneficial in asymptomatic patients with chronic AR and normal LVEF. Surgery is the only definitive therapy for severe chronic AR.
Percutaneous Interventional Therapy
Percutaneous Aortic Valves
In contrast to aortic stenosis, percutaneously implantable aortic prosthetic valves are not approved for the treatment of native AR at present in the United States. However, a percutaneous Jena valve specifically designed for isolated AR (JenaValve Technology GmbH) has been approved in Europe. The percutaneous aortic valve-in-valve procedure is becoming the primary means of treating failed aortic surgical bioprostheses (implantation of a transcatheter aortic valve [AV] inside a stenosed and/or regurgitant aortic surgical bioprosthesis).
Intraaortic Balloon Pump
The use of intraaortic pump is contraindicated in patients with AR.
Left Ventricular Assist Devices
LV mechanical support with a percutaneous LV assist device may provide hemodynamic support in patients with severe AR.
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