Management of aotic Regurgitation

Management of aotic Regurgitation

1. M anagement of Aortic Regurgitation

2. 2014 AHA/ACC guideline for the management of patients with Aortic Regurgitation A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. M anagement of Aortic Regurgitation

3. Acute Aortic Regurgitation CT imaging is highly accurate and primary approach for diagnosis of acute aortic dissection. MRI is rarely used in the acute setting because of patient instability. Angiography should be considered only when the diagnosis cannot be determined by non-invasive imaging or when the differential diagnosis is an acute coronary syndrome. TEE is helpful in intraoperative assessment of aortic valve function before and after the surgical intervention. TTE or TEE is indispensable in confirming the presence, severity, and etiology of acute AR; determining whether there is rapid equilibration of the aortic and LV diastolic pressures; visualizing the aortic root; and evaluating LV size and systolic function. Diagnosis and Follow-up M anagement of Aortic Regurgitation

4. Chronic Aortic Regurgitation TTE provides diagnostic information about the etiology and mechanism of AR (including valve reparability), severity of regurgitation, morphology of the ascending aorta, and LV response to the increases in preload and afterload. Imaging with TEE, CMR, or aortic angiography provides additional information when needed. Measures of LV systolic function (LVEF or fractional shortening) and LV end-systolic dimension (LVESD) or LV end-systolic volume are predictive of the development of HF symptoms or death in initially asymptomatic patients and are significant determinants of survival and functional results after surgery in asymptomatic and symptomatic patients. M anagement of Aortic Regurgitation

5. In asymptomatic patients with chronic AR (Stages B and C), treatment of hypertension (systolic blood pressure >140 mm Hg) is recommended. Vasodilating drugs, such as ACE inhibitors or ARBs, do not affect heart rate and thus may reduce systolic blood pressure without a substantial reduction in diastolic blood pressure in patients with chronic AR. In patients with severe AR who have symptoms and/or LV systolic dysfunction (Stages C2 and D) but a prohibitive surgical risk, GDMT for reduced LVEF with ACE inhibitors, ARBs, and/or sacubitril/valsartan is recommended. Medical Therapy M anagement of Aortic Regurgitation

6. In symptomatic patients with severe AR, aortic valve surgery is indicated regardless of LV systolic function. In asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF ≤55%), aortic valve surgery is indicated if no other cause for systolic dysfunction is identified. In patients with severe AR who are undergoing cardiac surgery for other indications, aortic valve surgery is indicated. 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/m 2 ). Timing of Intervention M anagement of Aortic Regurgitation

7. In patients with moderate AR who are undergoing cardiac or aortic surgery for other indications, aortic valve surgery is reasonable. In asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF >55%) 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). In patients with isolated severe AR who have indications for SAVR and are candidates for surgery, TAVI should not be performed. Timing of Intervention M anagement of Aortic Regurgitation

8. 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. 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. Choice of Intervention M anagement of Aortic Regurgitation