CT imaging is the primary approach for diagnosing acute aortic dissection, while TTE or TEE is used to assess acute aortic regurgitation (AR) by determining severity, etiology, and left ventricular function and size. For chronic AR, TTE is used initially to evaluate etiology, severity, and left ventricular response, with additional imaging like TEE or CMR as needed. Medical therapy focuses on controlling hypertension and heart failure. Aortic valve surgery is indicated for symptomatic severe AR or asymptomatic severe AR with left ventricular systolic dysfunction or enlargement. Surgery is also considered for moderate AR during other cardiac procedures or asymptomatic severe AR with declining left ventricular function.

1. Management of Aortic Regurgitation

2. 2014 AHA/ACC guideline for the management of patients
with Aortic Regurgitation
A report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines.
Management of Aortic Regurgitation

3. Acute Aortic Regurgitation
• CT imaging is highly accurate and primary approach for diagnosis of acute
aortic dissection.
• MRI is rarely used in the acute setting because of patient instability.
• Angiography should be considered only when the diagnosis cannot be
determined by non-invasive imaging or when the differential diagnosis is an
acute coronary syndrome.
• TEE is helpful in intraoperative assessment of aortic valve function before
and after the surgical intervention. TTE or TEE is indispensable in confirming
the presence, severity, and etiology of acute AR; determining whether there
is rapid equilibration of the aortic and LV diastolic pressures; visualizing the
aortic root; and evaluating LV size and systolic function.
Diagnosis and Follow-up
Management of Aortic Regurgitation

4. Chronic Aortic Regurgitation
• TTE provides diagnostic information about the etiology and mechanism of AR
(including valve reparability), severity of regurgitation, morphology of the
ascending aorta, and LV response to the increases in preload and afterload.
• Imaging with TEE, CMR, or aortic angiography provides additional
information when needed.
• Measures of LV systolic function (LVEF or fractional shortening) and LV end-
systolic dimension (LVESD) or LV end-systolic volume are predictive of the
development of HF symptoms or death in initially asymptomatic patients and
are significant determinants of survival and functional results after surgery in
asymptomatic and symptomatic patients.
Management of Aortic Regurgitation

5. • In asymptomatic patients with chronic AR (Stages B and C), treatment of
hypertension (systolic blood pressure >140 mm Hg) is recommended.
• Vasodilating drugs, such as ACE inhibitors or ARBs, do not affect heart rate
and thus may reduce systolic blood pressure without a substantial reduction
in diastolic blood pressure in patients with chronic AR.
• In patients with severe AR who have symptoms and/or LV systolic
dysfunction (Stages C2 and D) but a prohibitive surgical risk, GDMT for
reduced LVEF with ACE inhibitors, ARBs, and/or sacubitril/valsartan is
recommended.
Medical Therapy
Management of Aortic Regurgitation

6. • In symptomatic patients with severe AR, aortic valve surgery is
indicated regardless of LV systolic function.
• In asymptomatic patients with chronic severe AR and LV systolic
dysfunction (LVEF ≤55%), aortic valve surgery is indicated if no other
cause for systolic dysfunction is identified.
• In patients with severe AR who are undergoing cardiac surgery for
other indications, aortic valve surgery is indicated.
• In asymptomatic patients with severe AR and normal LV systolic
function (LVEF >55%), aortic valve surgery is reasonable when the LV is
severely enlarged (LVESD >50 mm or indexed LVESD >25 mm/m2).
Timing of Intervention
Management of Aortic Regurgitation

7. • In patients with moderate AR who are undergoing cardiac or aortic
surgery for other indications, aortic valve surgery is reasonable.
• In asymptomatic patients with severe AR and normal LV systolic
function at rest (LVEF >55%) and low surgical risk, aortic valve surgery
may be considered when there is a progressive decline in LVEF on at
least 3 serial studies to the low–normal range (LVEF 55% to 60%) or a
progressive increase in LV dilation into the severe range (LV end-
diastolic dimension [LVEDD] >65 mm).
• In patients with isolated severe AR who have indications for SAVR and
are candidates for surgery, TAVI should not be performed.
Timing of Intervention
Management of Aortic Regurgitation

8. • Patients with chronic severe AR may be referred for other types of cardiac
surgery, such as CABG, mitral valve surgery, or surgery for correction of
dilation of the aortic root or ascending aorta. In these patients, AVR will
prevent both the hemodynamic consequences of persistent AR during the
perioperative period and the possible need for a second cardiac operation
in the near future.
• Patients undergoing surgical repair or replacement of the aortic root or
ascending aorta may be candidates for aortic valve–sparing procedures.
• TAVI is rarely feasible, and then only in carefully selected patients with
severe AR and HF who have a prohibitive surgical risk and in whom valvular
calcification and annular size are appropriate for a transcatheter approach.
Choice of Intervention
Management of Aortic Regurgitation