Aortic Regurgitation Treatment & Management

In acute severe aortic regurgitation (AR), surgical intervention is usually indicated, but the patient may be supported medically with dobutamine to augment cardiac output and shorten diastole and sodium nitroprusside to reduce afterload in hypertensive patients.

In chronic severe AR, vasodilator therapy may be used in select conditions to reduce afterload in patients with systolic hypertension to minimize wall stress and optimize LV function; in normotensive patients, vasodilator therapy is not likely to reduce regurgitant volume (preload) significantly and thus may not be of clinical benefit.^[22]

The current American College of Cardiology/American Heart Association (ACC/AHA) guidelines say the following about vasodilator therapy:

• Vasodilator therapy is indicated for long-term therapy in patients with chronic, severe AR and symptoms of LV dysfunction but who are not candidates for surgery.
• Vasodilator therapy is reasonable for short-term therapy in patients with severe LV dysfunction and heart failure symptoms to improve their hemodynamic profile before proceeding with surgery.
• Vasodilator therapy is acceptable for long-term therapy in asymptomatic patients with severe AR and LV dilation with normal EF.

However, under the current guidelines, vasodilator therapy is not indicated for the following:

• Long-term therapy in asymptomatic patients with less than severe AR and normal EF
• Long-term therapy in asymptomatic patients with LV dysfunction who are candidates for surgery
• Long-term therapy in symptomatic patients with less than severe LV dysfunction who are candidates for surgery

Although diuretics, nitrates, and digoxin are sometimes used to help control symptoms in patients with AR, not enough data in the clinical literature justify routinely recommending or discouraging these therapies. Also, no data support drug therapy of any class in patients with less than severe AR.^[5]

Antibiotic prophylaxis prior to dental procedures is no longer routinely recommended for all patients with AR under current ACC/AHA guidelines.^[5] However, select patient groups for whom prophylactic antibiotic therapy prior to dental procedures may be reasonable include the following:

• Patients with prosthetic material in their hearts (such as artificial valves or valves repaired with prosthetic material)
• Patients with prior infective endocarditis
• Patients with the following forms of congenital heart disease (CHD):

  • Cyanotic CHD that is incompletely or not repaired (including patients with palliative shunts and conduits)
  • Repaired CHD using prosthetic material, for the first 6 months post-procedurally (ie, prior to endothelialization of the material)
  • Repaired CHD but at risk of inhibited endothelialization (ie, with residual defects at or adjacent to the site of the prosthetic material)
• Patients following cardiac transplantation who have valve regurgitation due to a structurally abnormal valve

Surgical treatment of AR usually requires replacement of the diseased valve with a prosthetic valve, although valve-sparing repair is increasingly possible with advances in surgical technique and technology.

Under current ACC/AHA guidelines^[5] , aortic valve surgery is recommended for patients with chronic severe AR under the following circumstances:

• Patient is symptomatic
• Patient is asymptomatic, with a resting EF of ≤ 55%
• Patient is asymptomatic, with LV dilation (LV end-systolic dimension >55 mm)

Additional circumstances in which aortic valve surgery may be reasonable include the following:

• Patient has moderate AR and is undergoing coronary artery bypass surgery or other surgery involving the ascending aorta
• Patient has severe AR with no symptoms, normal EF, and less severe LV dilation (LV end-systolic dimension >50 mm or LV end-diastolic dimension >70 mm) if the patient experiences (1) progressive LV dilation on serial imaging studies; (2) deteriorating exercise tolerance, or (3) abnormal hemodynamic responses to exercise, such as inability to augment blood pressure during a treadmill study

Ongoing improvements in surgical technique and technology have enabled many patients with even severe LV dysfunction to undergo surgery (rather than cardiac transplantation).^[23]

In patients undergoing aortic valve surgery for bicuspid aortic valve disease who also have a dilated or aneurysmal ascending aorta with a diameter of >4.5 cm, concurrent aortic root repair or replacement is indicated.

Aortic valve surgery is generally not indicated in asymptomatic patients with normal EF and less LV dilation (LV end-systolic dimension < 50 mm or LV end-diastolic dimension < 70 mm).

Mechanical versus bioprosthetic aortic valve

For patients undergoing aortic valve replacement, careful consideration should be given to the relative risks and benefits of mechanical versus bioprosthetic valves. Traditionally, mechanical valves have been thought to be more durable but require long-term anticoagulation with warfarin due to increased risk of thrombosis, whereas bioprosthetic valves carry a greater risk of long-term deterioration and risk of reoperation but avoid the need for long-term warfarin.^[24] In some cases, a clear choice is apparent (eg, a homografts is often preferred to a mechanical valve in the setting of active infective endocarditis).

While further discussion is beyond the scope of this article, the reader is referred to the current ACC/AHA guidelines, which include major criteria for aortic valve selection as well as recommendations for antithrombotic therapy (including aspirin for all prosthetic valve recipients along with long-term anticoagulation with warfarin for selected patients).^[5]

• Cardiologist
• Cardiothoracic surgeon

No specific dietary recommendations exist pertaining purely to AR. However, for patients with hypertension or hypervolemia (including peripheral edema or other heart failure symptoms), salt restriction may provide significant clinical benefit.

Current recommendations regarding activity in patients with AR is based mostly on expert opinion as there is a paucity of clinical trial data, including no convincing evidence to suggest that even strenuous periodic exercise worsens LV function in patients with AR.

Patients who are asymptomatic and have normal EF may safely participate in normal daily activities as well mild exercise and some forms of competitive exercise. However, isometric exercise is discouraged. The short-term safety of more vigorous exercise (such as with competitive athletics) may be estimated through the use of stress testing at a comparable level of exertion, but the long-term effects of such exercise is not known.