cardiovascular disorders
Aortic Regurgitation
Treatment of Aortic Regurgitation
Aortic valve replacement or repair Sometimes vasodilators, diuretics, and nitrates When aortic root dilatation is part of the mechanism of aortic regurgitation, angiotensin-receptor blockers may slow progression of root dilation, making them favored medications for patients with concomitant hypertension. These medications do not reduce the severity of aortic regurgitation or alter disease progression. Intervention is either surgical aortic valve replacement or (less commonly) valve repair. Percutaneous options are being developed ( Treatment reference ). An aortic bioprosthetic valve requires anticoagulation for 3 to 6 months postoperatively, but a mechanical valve requires lifetime anticoagulation using Choice of intervention (TAVI) is challenging because of the dilated aortic annulus and lack of sufficient leaflet calcification, leading to prosthetic valve migration and/or paravalvular leak. Patients who are not candidates for surgery benefit from Treatment (eg, with diuretics, vasodilators, nitrates). Beta-blockers should be used with caution because they block compensatory tachycardia and worsen AR by prolonging diastole. Intra-aortic balloon pump insertion is contraindicated because the diastolic balloon inflation worsens AR. Patients with severe AR who do not meet the criteria for intervention should be reevaluated by physical examination and echocardiography every 6 to 12 months. Antibiotic prophylaxis against endocarditis is no longer recommended for aortic regurgitation except for patients who have had valve replacement (see table). Intervention is indicated when AR is severe and is causing symptoms AR is severe and is causing LV dysfunction (EF≤55%, LV end-systolic dimension > 50 mm, or indexed to body surface area > 25 mm/m2) AR is severe and at least 3 serial studies show a progressive decline in EF to 55 to 60%, or progressive increase in LV end-diastolic dimension to>65 mm frequently have AR as well as an increased risk of Aortic Dissection . A high risk of aortic dissection may be the first indication for cardiac surgery, which should be undertaken when Ascending aortic diameter is> 55 mm Bicuspid valve is present with ascending aortic diameter 50 to 55 mm and aortic growth rate > 5 mm/year, aortic coarctation, or a family history of aortic dissection Marfan syndrome is present with ascending aortic diameter > 50 mm (or less if the aortic growth rate is > 5 mm/year) or a family history of aortic dissection at < 50 mm diameter When cardiac surgery is being done for other reasons, concomitant aortic surgery is indicated if the ascending aortic diameter is ≥ 45 mm. 1.Otto CM, Nishimura RA, Bonow RO, et al: 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.Circulation143(5):e35–e71, 2021. doi: 10.1161/CIR.0000000000000932 