This document discusses the management of aortic regurgitation. It begins by outlining factors to consider before starting treatment, including the severity of regurgitation and presence of other valve diseases or comorbidities. Medical management is indicated for severe regurgitation or moderate regurgitation with symptoms and involves controlling hypertension, limiting activity, and using vasodilators, diuretics, and other drugs. Surgical management involves aortic valve replacement. The document then discusses treatment options in more detail and provides guidelines on managing acute regurgitation, regurgitation in pregnancy, and other special situations.

1. NHF Cardiac Course
Management
Of
Aortic Regurgitation
Dr. Ashok Dutta
MBBS; FCPS(Med.);MD(Card.): FACC
Associate Professor & Senior Consultant
NHFH&RI, Dhaka

2. NHF Cardiac Course
Before starting treatment of AR-
Followings factors should be considered
Severity of AR.
Concomitant other valve disease (MVD)- AS,MR, MS.
Aortic root pathology (Secondary AR).
Hypertension- SBP>140 mmHg. In severe AR - DBP >60 mmHg.
CAD.
AF.
Comorbidities ( BA/COPD, CKD).
Mild to moderate AR – usually doesn‘t need any medication.
Medications- indicated in severe AR or moderate to severe AR with symptoms.
Rx of HTN : Crucial to ↓pressure overload.

3. NHF Cardiac Course
Treatment options
• Medical management:
General Mx: physical activity and diet.
• Mild to moderate AR- As per tolerance, usually doesn’t need limitation.
• Severe AR/ Moderately severe AR- Avoid competitive sports & vigorous
exercise.
• Isometric exercise ( weight lifting) is harmful for cardiac patients, Increase
regurgitant volume. Adrenaline like effect-↑HR, ↑BP, as occur in Hand
Gripping.
Pharmacological Mx/Drugs therapy.
• Surgical Management -
AV Replacement (AVR/SAVR) –
Mechanical Valve.
Bio prosthesis (Porcine/Bovine/Homograph).

4. NHF Cardiac Course
Medical management
• Vasodilators -
• ACE-I : Captopril, Enalapril, Lisinopril, Perindopril.
• ARB: Losartan, Valsartan, Telmisartan, Olmesartan,Candesartan.
• Nifedipine.
• Prazosin.
• Hydralazin.
• Na-Nitropruside.
• NO3.
• Diuretics.
• Beta Blocker ?.
• Digoxin.
• Prophylaxis against RHD & I.E.

5. NHF Cardiac Course
Medical therapy is not indicated in mild to moderate AR.
Why ?
• No definitive medical treatment can prevent disease progression.
• No prospective RCT regarding beneficial effect of vasodilator in
asymptomatic patients are available .
• But many short term studies showed benefits of ACE-I, Nifedipine, hydralazine.
• ACE-I & ARB reduce HF –hospitalization & AVR by 32 % in young
patients.
• Specially ACE-I and ARB , that have beneficial effects on myocardial
fibrosis and remodeling along with afterload reduction. CCB must be
long acting.

6. NHF Cardiac Course
Indications of ACE-I/ARB .
 Any degree of AR in hypertensive patients , good control of
hypertension with ACE-I, ARB w/w-out diuretics is beneficial (↓
Pressure overload).
 Symptomatic patient with moderate AR may be benefited with
Vasodilators and diuretics.
Severe AR with symptoms or w/out symptom in LVD.
Pre & post operative period- specially helpful in all patient with LVD (↓LVEF)
When AVR is not feasible, it improves symptoms and longevity.
 Any degree of AR with significant MR- vasodilator and diuretics are
helpful

7. NHF Cardiac Course
Other Vasodilators
Long acting Nifedipine useful as an antihypertensive but should
be avoided in LV dysfunction.
Prazosin & Hydralazin- less tolerated because of S/E.
Nitroprucide I.V. - in Acute AR or acute decompensated state of Chr. AR.
Nitrate- specially in patient with angina and IHD.
SBP>140 mmHg. in any grade of AR.
In Echo-proven severe AR - DBP >60 mmHg. Pt. should be considered as
hypertensive & needsRx

8. NHF Cardiac Course
Diuretics
Loop Diuretics
(HF)
• Frusemide
• Bumetanide (Urinide 1-5 mg.)
• Torasemide ( Dytor/Dilast
2.5-5-20 mg.).
K-sparing Diuretics
( In combination –Loop
Diuretics)
• Spironolactone -
25-100 mg.
• Epliron -25-50 mg.
Anti-HTn
In combination w ACE-I/ARB.
• Hydrochlorthiazide
6.25-25 mg.
• Chlorthalidone 12.5-
25 mg.
• Indpamide 1.5 mg.

9. NHF Cardiac Course
BB in AR
( RHD, Marfan’s, LDS)
BB is relatively C/I in AR because it ↑ Diastolic time→ regurgitant
volume ↑ → ↑ LV dilatation .
But when there is LV dysf. & LV failure and marked tachycardia /AF-
FVR, it can be used ( specially Carvidilol) as an HF drug.
AR with aortic root dilatation- BB is useful in Marfan’s syndrome and
other CTD.

10. NHF Cardiac Course
Digoxin in HF
(3rd. line Drug. Next to ACE-I, BB, Diuretic)
• Chronic AF with FVR.
• Hugely dilated LV with ↓↓LVEF.
• Symptomatic HF.
• Specially when AR is associated with MS or MR.

11. NHF Cardiac Course
AF in VHD
• Commonest Cause of AF worldwide – Hypertensive Heart Disease.
• In S.E Asia- RHD is the commonest cause-
• MS – 30-50% over long term F/U
• MS with MR.
• MR.
• AS
• AR- least common cause.
• So AF is not uncommon in MS + AR (MVD).
• New onset of AF is a common cause of sudden deterioration of HF in any VHD.
So emergency control of Rate & Rhythm is necessary. Because in AV disease or
MR, already compromised LV function rapidly deteriorate with AF-FVR.

12. NHF Cardiac Course
Rate control & Anticoagulation in AF .
• Rate Control.
• Rhythm control.
• Anti-coagulation to prevent
stroke.
• For rate/Rhythm control – BB, CCB,
Amiodarone, Digoxin.
• Warfarin - in moderate to severe MS.
• In AR or MR – DOAC/NOAC.
• In AVR- depends on type of prosthetic
Valve.

13. NHF Cardiac Course
Mx of Acute AR
( similar to acute MR-after MI, PTMC)
• Causes of Acute AR: I.E, Aortic
dissection( marfan’s / Loeys-
Dietze syndrome), trauma.
• C/F: Sudden shock, acute
pulmonary edema. HR>100
bpm, Systolic BP<100 mmHg.
• Acute on Chr. Mild/moderate
AR- tolerate better.
• Same as in acute MR.

14. NHF Cardiac Course
Rx of acute AR
(AVR)
General mx- Propped up position,o2 inhalation, sedation with morphine I.V.
Inotropes - Dobutamine/Dopamine/NE- to improve hemodynamics.
IV vasodilators: Nitrate/Nitropruside/Hydralazine if BP permits.
Diuretic.
IABP & ECMO- contraindicated in AR (c.f. Acute MR)
Impella- not useful but may be useful in acute MR.
In case of I.E – if the pt. can be stabilized with medical management, surgery
may be deferred for a week with extensive antibiotic therapy.
*****Acute MR, after PTMC- Mx is same.

15. NHF Cardiac Course
Surgery

16. NHF Cardiac Course
Surgery for Primary AR.
(RHD,I.E, Bicuspid AV)
AV Replacement (AVR/SAVR):
Mechanical Valve.
Bio prosthesis (Porcine/Bovine/Homograft).
AV repair :
is always preferable but challenging & less feasible
because poor outcome.
MV repair is always preferable & mostly feasible.

17. NHF Cardiac Course
Valve Replacement Vs. Repair
• Repair is always better than replacement ,if done perfectly by expert
team.
• AV repair is more difficult than MV repair.
• Stenotic valve repair is more difficult than regurgitant valve.
• Metallic prosthesis is more durable than Bio-prosthesis (10-15 yrs.)
• Aortic prosthesis is more durable because it is less prone to degeneration,
calcification, dysfunction and thrombosis than prosthetic MV.
• Why MV is more prone i) In diastole-low flow from LA to LV =>
thrombus/microthmombus deposition ii) During systole – high pressure effect from LV
contraction-120-150 mmHg.

18. NHF Cardiac Course
Secondary AR
(Marfan’s, LDS, A. dissection)
Aortic Root Surgery ( with valve sparing/Repair/replacement) by
• Bentall Procedure/Modified Bentall.
• DAVID Procedure.
• Frozen Elephant Trunk (FET).
• TEVAR (Thoracic Endovascular Repair).
• Ross procedure.
• Indication of Root surgery :
• Root Diameter : Bicuspid AV > 55 mm.
• Marfan’s > 50 mm. If +ve F/H of dissection, >45 mm.
• In LDS- >45 mm.
• Root surgery is technically difficult with high mortality (10%).

19. NHF Cardiac Course
AVR or Root procedure ?
• AR in RHD- only AVR. Root is normal/mildly dilated.
• Hereditary - Marfan’s , Loeys-Dietz syndrome(LDS)-
• Root surgery is primary procedure with/w-out valve Repairing/ Sparing or
replacement.
• Bicuspid AV- Either one or may need both.

20. NHF Cardiac Course
TAVR/TAVI in AR
(Trancatheter AVR)
• Not indicated in Pure AR , because of absence of ca+, anchoring
difficulties, chance of dislodgment.
• In Mixed AS with AR ( degenerative ) in elderly patient , it is
feasible .

21. NHF Cardiac Course
ESC Guideline-2017

22. NHF Cardiac Course

23. NHF Cardiac Course
Indication of Surgery in Severe AR –
best predictors/parameters
1. Symptoms : NYHA class-III-IV.
2. LV systolic Function: LVEF -<50%. GLS ( Global longitudinal Strain).
3. LVIDs ( LVESD ) > 50 mm. or 25 mm/m2 BSA
4. LVIDd /LVEDD : >70 mm.
5. Aortic Root dilatation: predictor for root surgery.
• Presence of any ❶ of the first ❹ parameters –is the indication of
surgery.

24. NHF Cardiac Course
Mild to
Moderate
AR. F/U-1-2 yrs.
Symptomatic
Look for
concomitant other
valve lesion /IHD
/othr
Reassess-
(Cl/F, Physical
EXAM.ECG,CXA &
Echo)
No
Asymptomatic
No Rx for AR.
Rx HTN , other
risk factors
ETT/Cath.
YES
Rx
accordingly

25. NHF Cardiac Course
Severe
AR
Symptomatic
NYHA-I-IV
F/U-3-6 m.
LVEF=N,
LV-Dilatation
Moderate.
Vasodilator+Diuretic.
F/U 3 monthly w/Clinical &
Echo-evaluation
If Rapidly progressive-Surgery.
LVEF=N.
LV-moderately
Dilated
Asymptomatic
LVEF <50%.
LV –severely
Dilated
F/U-6-12 m.
No Rx /ACE-I
Rx of HTn, Risk
Factors.
Surgery
Medical RX
LVEF <50%.
LV –severely
Dilated
I-II
Surgery
Medical RX

26. NHF Cardiac Course
Special Situations
General or Non-Cardiac Surgery in VHD.
Pregnancy & AR.
Mixed/ Multivalvular Disease (MVD).
CAD and AR.
AR with Root aneurysm.

27. NHF Cardiac Course
Risk stratification during Major Gen. N/C Surgery
• Pre-Operative evaluation with
• Echocardiography.
• Functional status assessment is vital( Pivotal step) before any general surgery.
TMT or daily life functional status.
• Low risk Gen. surgery- safe .
• Mild to moderate AR, Asymptomatic, normal LVEF, mild to moderate
LV dilatation- Non-cardiac surgery is safe & low risk.
• Severe AR, symptomatic – high risk for Gen. surgery.
• Severe AR, asymptomatic- Intermediate risk. Non-cardiac surgery may
be done if needed strictly with close cardiac monitoring and after
optimization of medical therapy.

28. NHF Cardiac Course
Risk stratification in Pregnancy & Gen.N/C Surgery

29. NHF Cardiac Course
Pregnancy & AR
-Physiology .
• In Pregnancy there is tachycardia, Vasodilatation and fall of SBP (
Hormonal effect). That reduces the Regurgitation fraction and regurgitant
volume.
• IVC Compression by Gravid Uterus => Venous return.(SVC occlusion Device in HF).
• In pregnancy blood volume increased by 30-50%. So CO and SVO also
increase. So it is detrimental .
• During labor – Blood volume further increases by auto-transfusion from
placenta and uterus, specially in 2nd. Stage of labor.
• Shortly after delivery: Decompression of IVC , ↑ venous return,
↑LVEDP. It may aggravate pulmonary edema.

30. NHF Cardiac Course
Risk stratification for pregnancy.
• Pre-Operative evaluation with
• Echocardiography.
• Functional status assessment is vital( Pivotal step) before any general surgery.
TMT or daily life functional status.
• Mild to moderate AR, Asymptomatic, normal LVEF, mild to moderate
LV dilatation- Pregnancy is safe & low risk.
• Severe AR, symptomatic – high risk pregnancy .
• Severe AR, asymptomatic- Intermediate to high risk pregnancy.
• LUCS is preferable during delivery in intermediate & high risk pregnancy.

31. NHF Cardiac Course
Mixed Valvular
( single valve w both stenosis & regurgitation)
& Multivalvular Disease (MVD)
• Commonest Mixed VD : MS with MR
• Commonest multivalvular disease: MS with AR.
• Worse combination- MR and AR.
• Rarest combination - MS with AS.
• Secondary TR is very common in combination with left sided primary valve disease.

32. NHF Cardiac Course
Rx of Mixed VD.
• Moderate AR with-
• Moderate AS = Severe Aortic Valve Disease => AVR.
• Severe MS- PTMC of MV.
MV Repair+AVR / DVR.
• Moderate MR- MV Repair +AVR / DVR.
• DVR- always better to avoid. Per-operative mortality w DVR is 10%.

33. NHF Cardiac Course
Commonest MVD - MS with AR.
Both lesions are underestimated by Doppler.
Qs. AR-mild to moderate with Severe MS .
 PTMC for MS if valve is suitable for
ballooning.
AR- medical Mx, well tolerated over 5-10
yrs.
If surgery needed- AVR with MV-repair.
DVR- always better to avoid. Per-operative
mortality w DVR is 10%, same is true for Re-
Do surgery.

34. NHF Cardiac Course
Worse MVHD- AR with MR
Worse combination.
MR may be organic or functional.
Rapidly developed symptoms, PAH and
LV dilatation & dysfunction.
Postoperative mortality is highest with
DVR.
Better option is AVR+ MV-repair or
annuloplasty.
Medical therapy w – ACE-I/ARB+Diuretic.
Moderate AR with moderate MR- may
need surgery.

35. NHF Cardiac Course
Mixed Single Valve Disease- AR with AS.
• AS may be overestimated by Doppler ,
because of AR produce higher flow
across AV.
• So 3D is better than Doppler.
• Symptoms and LV dysfunction
determines the time of Surgery-AVR.
• LVIDd & LVIDs are not good predictors
and parameter..
• TAVR may be an option in advance
age.
• Moderate AS +moderate AR=Severe
AV disease. AVR as early as possible
before development of LVD.
• Even NYHA class-III-II symptoms may
need AVR.

36. NHF Cardiac Course
MS with AS
Rarest combination.
• Well tolerated.
• MS is protective.
• AVR+ MV repair or Replacement.

37. NHF Cardiac Course
AR with CAD
• Moderate AR in patient with CAD needed CABG – if Aortic root is not
dilated , Do only CABG. Role of AVR is controversial if aorta is not
dilated, because here AR progression is very slow.

38. NHF Cardiac Course
I.E. prophylaxis
Not routinely used.
Prosthetic valves or prosthetic material used in valve repair.
Previous infective endocarditis.
CHD with AR.
Qs.Rheumatic prophylaxis with Penicillin is not effective to prevent I.E.
during dental procedure.
Causative organism for ARF/RHD is GAS ( Group A Beta hemolytic Streptococcus).
Oral cavity harbors ἀ Hemolytic streptococcus, usually develops resistance
to penicillin.

39. NHF Cardiac Course
Prognosis of VHD
1. Severity of lesions.
2. Etiology: Bicuspid AV > RHD AR>
Hereditary.
3. Prognosis of Regurgitant lesion is
better than stenotic lesion.
4. Proximity of valvular lesion to
pulmonary Circulation & it’s
hemodynamic effects of cardiac
chambers (rule of thumb).

40. NHF Cardiac Course
Clinical Course and prognosis of AR
• Mild to moderate AR : excellent outcome.
• Mod. Severe to Severe AR ( Gr-III-IV ) : Favorable prognosis for many
years.
• Asymptomatic (gr-III-IV): 5 yrs. survival is 75%, 10 yrs. survival is 50%.
• Once symptoms develops, go downhill rapidly as in AS.
• AR average survival- ❷yrs. after development of HF and❹ yrs.
after Angina.
• AS average survival – HF- ❷ yrs. Syncope-❸yrs. Angina- ❺ yrs.

41. NHF Cardiac Course
Bad prognostic Features of AR.
Clinical Features.
Advance age.
NYHA –III-IV or Crescendo symptoms (
rapidly progressive symptoms of HF).
Disappearances of Peripheral signs of AR.
Shifted diffuse apex beat with S3 gallop.
Shortening of diastolic murmur & Austin
Flint murmur.
Congenital (BAV)>Rheumatic> hereditary
Other Comorbidities ( MVD,CAD,COAD,
CKD)
Investigations
ECG- LVH with ST-T changes. AF. IVCD.
CXA- CM >17 cm.
Echo- LVEF <50 %, markedly
dilated LV (LVIDs >25 mm/m2
BSA, LVIDd>65 mm).
Aortic Root dilatation.

42. NHF Cardiac Course
Take Home messages
For Mx of any disease, knowledge of etiology-pathology &
pathophysiology-hemodynamics is an important issue.
LV function is a good predictor of all CVD including CHD and their
intervention/surgical outcome.
Any Valve surgery or Repair is the introduction of new disease
process inside body. ESC guideline-2017. Mx of VHD.
So perfect timing of surgery (not so early, not so delayed) is crucial.

43. NHF Cardiac Course
Thank You

44. NHF Cardiac Course
Follow up of AR patient
• .
LVEF
N=>55%.
Red <50%
LVIDd
Mild 55-60 mm.
Moderate 60-70
Marked >70mm
LVIDs
Mild=40-45 mm.
Moderate=45-50 mm.
Severe= >50 . 25mm/m2
BSA
Symptom
s
Stable
Echo/Cl.
F/U (Cl/Echo)
Mild AR Normal Normal . Normal. No yes 1-2 yearly
Moderate to
moderately
Severe AR
Normal Mild to Moderate Mild to Moderate No/Yes. Yes/No 1-2 yrly.
If rapid
progression/Root
dilatn.- more
frequent F/U.
Severe AR Normal/
Reduced
<50%
Mod. To severely
dilated .>70 mm
Moderate to markedly
dilated >50 mm.
25 mm/m2 BSA
Yes/No No < 1 yr.
3-6 monthly. If 1st.
Diagnosed/ rapid
progression.**

45. NHF Cardiac Course
Similarities of AR & MR
(Aetiology, Pathophysiology, S/S and Echo-findings)
• Both are better tolerated and better prognosis than corresponding
stenotic lesion.
• Pathophysiology has got similarities i.e. volume overload in both,
additional pressure overload in MR.
• Acute regurgitation need Surgery ( I.E. CTD, Trauma). Bridging
management is same (IABP is C/I in AR . ECMO useful)
• Treatment options are also similar i.e. vasodilator, Diuretic.
• Echo-Gradings: Reasonably similar.

46. NHF Cardiac Course
Grade of
Regurgitation
Regurgitant
Fraction/Volm
Vena Contracta AR Jet width/LVOT
Mild AR. <30% of stroke volm < 3 mm < 30% of LVOT dia.
Mild MR <30% of stroke volm < 3 mm < 20% of LA size
Moderate AR 30-50 % 3-6 mm 30-65%
Moderate MR 30-50 % 3-7 mm 20-40%
Severe AR >50 % >6 mm >65 %
Severe MR >50% >7 m >40%

47. NHF Cardiac Course
Prognosis as per age of patients group
average age=69 yrs. in graph.
• Average age is 40 yrs. with normal LV
and no symptom :
• 1% mortality per yrs.
• 6% develops symptoms or LVD per year.
• So 45% remain asymptomatic and good
LVEF after 10 year.
• Ref. JACC-2008; 1.1.
• Br-3447

48. NHF Cardiac Course
Prognosis of AR
Asymptomatic & normal LV
–age=69 years
Survival after Symptoms appears,
NYHA-II-IV

49. NHF Cardiac Course
Murfan’s syndrome & Loeys-Dietz syndrome.
LDS- earlier CV death from dissection.

50. NHF Cardiac Course
LDS aorta

51. NHF Cardiac Course
Severe
AR
Symptomatic
NYHA-I-IV.
LVEF=N,
LV-Dilatation
Moderate.
High Risk
LVEF=N.
LV-moderately
Dilated
Asymptomatic
LVEF <50%.
LV –severely
Dilated
Intermediate
Risk
for Major N/S
Surgery &
Pregnancy
LVEF <50%.
LV –severely
Dilated
I-II
High Risk

52. NHF Cardiac Course
Valve
Disease
Hemodynamic
effects
Aorta LV LA Pulm.
Circulatio
n
AR Volume overload Yes Yes Yes Yes
AS Pressure Overload No Yes Yes Yes
MR Volume+
pressure over
No Yes Yes Yes
MS Pressure –
syst+Dias
No No Yes Yes

53. NHF Cardiac Course
Pregnancy , AR with Root dilatation
Non-Rheumatic AR
• Marfan’s syndrome, CTD, BAV-
• Irrespective of grade of AR,
• Root dilatation >45 mm is high risk for pregnancy because of chance of
aortic dissection( about 10%), deterioration of AR, LVEDP, LVF and
development of arrhythmia, SCA.
• So pregnancy is C/I.
• If already conceived, pregnancy should be terminated.
• In late stage of pregnancy , if fetus is viable and matured , LUCS is
indicated . LUCS is hemodynamically less traumatic than NVD.
• It is also true to any patient who is severely symptomatic (NYHA-
III-IV), LV Dysfunction or gross LV dilatation.

54. NHF Cardiac Course
Pregnancy after AVR
(Metallic ).
AVR –if therapeutic INR is achieved with warfarin of ≤5 mg /day, it
should be continued throughout the pregnancy. Change to
UFH/LMWH before delivery (48-72 hrs.) , restart after not more than
24 hrs.
 If higher dose of warfarin needed, to prevent embryopathy , first
trimester should be managed with LMWH twice daily dose with strict
anti-Xa monitoring after4-6 hr. of injection (therapeutic range 0.8-1.2
U/ml), warfarin afterwards.
Patient’s party counselling.