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Aortic Valve Replacement and Repair (AVR) for Aortic Regurgitation

Home Services Aortic Valve Replacement and Repair (AVR) for Aortic Regurgitation

The natural history of chronic aortic regurgitation is well recognized. The asymptomatic patient who has moderate to severe aortic regurgitation may not have symptoms for many years. In seven studies,1–7 490 asymptomatic patients with moderate to severe aortic regurgitation were followed for a mean of 6.4 years. Based on these studies, the following can be concluded about asymptomatic chronic aortic regurgitation with normal left ventricular systolic function (i.e., an ejection fraction of 50 percent or greater)8:

  1. The rate of progression to symptoms and/or left ventricular dysfunction is less than 6 percent per year.
  2. The rate of progression to asymptomatic left ventricular dysfunction is less than 3.5 percent per year.
  3. The rate of sudden death is less than 0.2 percent per year.

In patients with asymptomatic chronic aortic regurgitation and left ventricular dysfunction, the rate of progression to symptoms is higher than 25 percent per year. In symptomatic patients, the mortality rate is greater than 10 percent per year.8

Although there is only a small chance of sudden death or left ventricular dysfunction in patients with asymptomatic chronic aortic regurgitation, these adverse events are possible. Therefore, it is important to follow asymptomatic patients for the development of symptoms and to examine them regularly to detect progression of severity. In addition, periodic quantitative evaluation of left ventricular function is necessary in patients with moderate to severe aortic regurgitation. When the history of exercise tolerance or symptoms is equivocal, exercise stress testing can be helpful.

The presence of aortic regurgitation, even when it is moderately severe, is not necessarily an indication for surgery. When surgery is needed, aortic valve replacement or repair, is usually required. Prosthetic valves, whether mechanical or biologic, have problems with durability, paraprosthetic leaks, thromboembolism and increased susceptibility to infective endocarditis. The decision to replace the valve requires that these potential problems be considered to represent less danger to the patient’s well-being than continuing medical management.

When should surgery be done for Aortic Regurgitation?

  1. NYHA class III or IV symptoms, regardless of left ventricular function
  2. NYHA class II symptoms with normal left ventricular function (ejection fraction of 50 percent or greater) and evidence of progressive left ventricular dilatation or decreasing ejection fraction at rest on serial studies, or evidence of decreasing exercise tolerance on exercise stress testing.
  3. Canadian Heart Association class II or higher angina with or without coronary disease.
  4. Mild to moderate left ventricular dysfunction (ejection fraction of 25 to 49 percent).
  5. Moderate to severe aortic regurgitation and undergoing coronary artery bypass grafting or other valvular surgery.
  6. If symptoms are absent and normal there is left ventricular systolic function but severe dilatation of the left ventricle (end-diastolic diameter of greater than 75 mm or end-systolic diameter of greater than 55 mm)
  7. Severe left ventricular dysfunction (ejection fraction of less than 25 percent)
  8. If symptoms are absent and there is normal systolic function at rest and progressive moderate degrees of left ventricular dilatation (end-diastolic diameter of 70 to 75 mm, end-systolic diameter of 50 to 55 mm)
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