Acute Aortic regurgitation
Patients with acute aortic regurgitation usually require urgent surgery, aortic valve replacement, or repair. IV vasodilators (Nitroprusside) and sometimes inotropic agents (Dobutamine) can be used to stabilize the patient if the surgery is delayed; this should be done at an intensive care unit.
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Intervention
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Scenario
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- Emergent surgery should be done: aortic valve resuspension with graft replacement of the ascending aorta. This surgery helps in the preservation of the native valve and the resolution of valve incompetence.
-Temporal pharmacotherapy can be initiated depending on blood pressure values. If the patient is hypertensive: a vasodilator with cautious use of beta-blockers (The usual heart rate target in patients with Aortic dissection on beta blocker is < 60 beats per minute before initiation of vasodilators; in concomitant Acute aortic regurgitation, a higher target is more appropriate.)
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Acute severe aortic regurgitation with Aortic dissection
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Investigate the cause:
- Endocarditis: antibiotic therapy unless there is an indication for urgent surgery.
- Aortic dissection: ascending aorta graft replacement might restore normal aortic valve function without having to undergo an aortic valve replacement procedure.
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Hemodynamically stable patients with Mild-moderate acute aortic regurgitation
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Medical therapy might be initiated to stabilize the patient but surgery (Valve and root replacement) should not be delayed
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Severe acute Aortic Regurgitation and Endocarditis with paravalvular abscess
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Valve repair are possible
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Severe acute Aortic Regurgitation and Fenestrated cusp rupture
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Surgery is the cornerstone treatment for severe aortic regurgitation patients who are either symptomatic or asymptomatic with LV dysfunction. It is indicated depending on symptoms, LV status, or dilatation of the aorta. Valve replacement surgery is the standard procedure for the majority of patients.
- In symptomatic patients with severe aortic regurgitation, surgery is recommended regardless of LV systolic function.
- In asymptomatic patients with severe aortic regurgitation, left ventricular end-diastolic diameter (LVESD) > 50 mm or > 25 mm/m2 BSA (in patients with small body size), or resting LVEF <= 50%, surgery is recommended.
- In patients with asymptomatic aortic regurgitation whose systolic blood pressure is > 140, treatment of hypertension is recommended. ACEIs, ARBs, or dihydropyridine calcium channel blockers are preferred as they may reduce systolic blood pressure.
- In patients with severe symptomatic aortic regurgitation who cannot undergo surgery due to surgical risk, an ACEI or dihydropyridine calcium channel blocker may provide symptomatic improvement.
- In patients with severe symptomatic aortic regurgitation and LV dysfunction who cannot undergo surgery, GDMT, ACEI, ARB, or ARNI (Sacubitril-Valsartan) are recommended.
- Aortic valve surgery is indicated in patients with severe aortic regurgitation who are undergoing cardiac surgery for other purposes.
- According to the American College of Cardiology, surgery is recommended in asymptomatic severe aortic regurgitation and LV systolic dysfunction (<= 55%) if no other cause of the dysfunction has been identified. whereas surgery might be considered in this case according to European guidelines.
- In asymptomatic patients with severe aortic regurgitation, normal LVEF (>55%), progressive severe LV dilation (LVEDD > 65%), or proof of progressive decrease in LVEF on at least three serial studies to the normal range (55–60%), surgery is suggested if the surgical risk is low.
- Surgery is suggested in moderate aortic regurgitation where the patient is undergoing other cardiac surgery.
- The transcatheter aortic valve implantation procedure (TAVI) should not be performed in patients with isolated severe aortic regurgitation who are surgery candidates and are indicated for surgical aortic valve replacement (SAVR).
- In young patients with aortic root dilation, valve-sparing aortic root replacement is recommended if done by an experienced center, and durable results are expected.
- In Marfan syndrome patients with aortic disease and a maximum ascending aortic diameter of >= 50 mm, ascending aortic surgery is recommended.
- Consider ascending aortic surgery in patients with aortic root disease and maximal ascending aortic diameter of
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- >= 55 mm in all patients.
- >= 45 mm in patients with Marfan syndrome and additional risk factors or TGFBR1 or TGFBR2 mutations (including Loeys-Dietz syndrome). Note: In women with low BSA, TGFBR2, and severe extra-aortic features, a lower threshold (40 mm) may be considered.
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- >= 50 mm in patients with bicuspid valves with additional risk factors or coarctation.
- Additional risk factors: family history of aortic dissection or personal history of spontaneous vascular dissection; severe aortic or mitral regurgitation; pregnancy desire; uncontrolled systemic arterial hypertension; and/or aortic size increase >3 mm/year (using serial echocardiography or CMR measurements at the same level of the aorta confirmed by ECG-gated CCT).
- Aortic root or tubular ascending aorta replacement should be considered when the maximal ascending aortic diameter is >= 45 and the surgery is primarily indicated for the aortic valve.
References
- https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Valvular-Heart-Disease-Guidelines
- https://www.uptodate.com/contents/acute-aortic-regurgitation-in-adults
- https://www.uptodate.com/contents/natural-history-and-management-of-chronic-aortic-regurgitation-in-adults
- https://www.jacc.org/doi/pdf/10.1016/j.jacc.2020.11.018?_ga=2.63734831.1204631815.1700082971-977878038.1614442144
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