Table of contents
Aortic regurgitation
What's new
Updated 2021 ACC/AHA and ESC/EACTS guidelines for the diagnosis and management of aortic regurgitation.
Background
Overview
Definition
AR, also known as aortic insufficiency, is a structural heart disease characterized by diastolic flow of blood across the aortic valve, from the aorta into the left ventricle.
1
Pathophysiology
AR may be due to malfunction of the valve leaflets themselves, dilatation of the aortic root and annulus, or a combination of these factors.
2
Epidemiology
The prevalence of AR in the US is estimated at 500 persons per 100,000 population.
3
Disease course
Chronic AR causes volume overload of the left ventricle, with ventricular dilation and systolic dysfunction, and clinical symptoms of HF. Acute AR results in acute HF, and can progress to cardiogenic shock due to an uncompensated decrease in effective stroke volume.
2
Prognosis and risk of recurrence
Moderate or severe AR is associated with significant morbidity and mortality. In highly symptomatic patients (NYHA functional class 3-4), annual mortality rates of approximately 25% have been reported.
4
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of aortic regurgitation are prepared by our editorial team based on guidelines from the European Society of Hypertension (ESH 2023), the American Heart Association (AHA/ACC 2021), the European Society of Cardiology (ESC/EACTS 2021), and the Society of Thoracic Surgeons (STS 2013)....
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Diagnostic investigations
TTE
As per ACC/AHA 2021 guidelines:
Obtain TTE for assessment of the cause and severity of regurgitation, LV size and systolic function, prognosis, and timing of valve intervention in patients with signs and symptoms of AR.
B
Obtain TTE for evaluation of the presence and severity of AR in patients with bicuspid aortic valve or with known dilation of the aortic sinuses or ascending aorta.
B
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Further imaging
Medical management
Pharmacotherapy
As per ESH 2023 guidelines:
Use the same BP thresholds and targets in patients with aortic insufficiency as for the general population with hypertension.
B
Initiate treatment with drugs reducing afterload, including renin-angiotensin system blockers and CCBs, in patients with aortic insufficiency.
B
Surgical interventions
Indications for surgery, symptomatic patients: as per ACC/AHA 2021 guidelines, Perform aortic valve surgery in symptomatic patients with severe AR (stage D) regardless of LV systolic function.
B
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Indications for surgery (asymptomatic patients)
Specific circumstances
Pregnant patients, before pregnancy: as per ACC/AHA 2021 guidelines, Obtain clinical evaluation and TTE in female patients with suspected valve disease contemplating pregnancy.
B
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Pregnant patients (during pregnancy)
Patients with aortic stenosis
Patients with coronary artery disease
Patients undergoing non-cardiac surgery
Follow-up and surveillance
Post-procedural follow-up: as per ACC/AHA 2021 guidelines, Obtain baseline port-procedural TTE followed by periodic monitoring with TTE depending on type of intervention, length of time after intervention, ventricular function, and concurrent cardiac conditions in asymptomatic patients with any type of valve intervention.
B