Guidelines Summary
Guidelines for the management of patients with valvular heart disease (VHD) were published in August 2021 by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), [42] including the following recommendation on aortic valve disease:
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Surgery is recommended for symptomatic patients with severe aortic regurgitation regardless of left ventricular (LV) function; for asymptomatic patients with (a) LV end-systolic diameter (LVESD) >50 mm or >25 mm/m2 body surface area (if body size is small) or (b) resting left ventricular ejection fraction (LVEF) ≤ 50%; and for both symptomatic and asymptomatic patients undergoing coronary artery bypass grafting (CABG) or surgery of the ascending aorta or of another valve.
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Valve-sparing aortic root replacement is recommended for young patients with aortic root dilation. Ascending aortic surgery is indicated for Marfan patients with aortic root disease and maximal ascending aortic diameter ≥50 mm.
In 2014, the AHA/ACC released a revision to its 2008 guidelines for management of patients with VHD; [4] and ESC/EACTS issued a revision of its 2007 guidelines in 2012. [43] The Society of Thoracic Surgeons (STS) published guidelines for the management of aortic valve disease in 2013. [9]
The 2014 AHA/ACC guidelines classify progression of chronic aortic regurgitation (AR) into 4 stages (A to D) as follows: [4]
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Stage A: At Risk of AR
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Stage B: Asymptomatic with progressive AR (mild to moderate)
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Stage C: Asymptomatic with severe AR
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Stage D: Symptomatic with severe AR
Both AHA/ACC and ESC/EACTS guidelines require intervention decisions for severe valvular heart disease (VHD) should be based on an individual risk-benefit analysis. Improved prognosis should outweigh the risk of intervention and potential late consequences, particularly complications related to prosthetic valves. [4, 43]
Recognizing the known limitations of the EuroSCORE (European System for Cardiac Operative Risk Evaluation) and the STS (Society of Thoracic Surgeons) score , the AHA/ACC guidelines suggest using STS plus three additional indicators: frailty (using accepted indices), major organ system compromise not to be improved postoperatively, and procedure-specific impediment when assessing risk. [4]
Vasodilator Therapy
The current ACC/AHA guidelines provide the following recommendations for vasodilator therapy [4] :
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Vasodilator therapy is indicated for long-term treatment in patients who have severe chronic AR and symptoms of LV dysfunction but who are not candidates for surgery.
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Vasodilator therapy is reasonable for short-term therapy in patients with severe LV dysfunction and heart failure symptoms, in order to improve their hemodynamic profile before surgery
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Vasodilator therapy is acceptable for long-term therapy in asymptomatic patients with severe AR and LV dilation with normal EF
Under the guidelines, vasodilator therapy is not indicated for the following:
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Long-term therapy in asymptomatic patients with less than severe AR and normal EF
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Long-term therapy in asymptomatic patients with LV dysfunction who are candidates for surgery
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Long-term therapy in symptomatic patients with less than severe LV dysfunction who are candidates for surgery
The 2012 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines recommend short-term use of vasodilators and inotropic agents to improve the condition of patients with severe heart failure before proceeding with valve surgery. In patients with severe chronic AR and heart failure, vasodilators are useful in the treatment of those who have hypertension, those in whom surgery is contraindicated, or patients whose LV dysfunction persists postoperatively. [43]
Surgical Intervention
A comparison of surgical recommendations for aortic regurgitation is provided in the table below.
Table 2. Guidelines for Aortic Regurgitation Surgical Intervention (Open Table in a new window)
Aortic valve replacement (AVR) indications Note: STS guidelines recommend “valve replacement or valve repair” |
AHA/ACC (2014) [4] |
ESC/EACTS (2012) [43] |
STS (2013) [9] |
Symptomatic severe AR |
Class I |
Class I |
Class I |
Asymptomatic chronic severe AR and left ventricular ejection fraction (LVEF) ≤50% |
Class I |
Class I |
Class I |
Severe AR when undergoing other cardiac surgery |
Class I |
Class I |
Class I |
Asymptomatic severe AR with normal LVEF (≥50%) but with severe LV dilation (LVESD >50mm) |
Class IIa-Reasonable |
Class IIa-Reasonable |
Class IIa-Reasonable |
Moderate AR when undergoing other cardiac surgery |
Class IIa-Reasonable |
Class IIb-Consider |
|
Asymptomatic severe AR and normal LVEF (≥50%) but with progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low |
Class IIb-Consider |
Class IIa-Reasonable |
Class IIb-Consider |
Not indicated for asymptomatic patients with mild, moderate, or severe AR and normal LV systolic function at rest when the degree of LV dilation is not moderate or severe |
Class III |
In 2015, the ACC/AHA released a guideline clarification statement addressing indications for early surgical intervention for associated enlargement or aneurysm of the ascending aorta in patients with bicuspid aortic valve (BAV) with the following recommendations: [44]
Intervention to repair or replace the aortic root (sinuses) or replace the ascending aorta is indicated in asymptomatic patients with BAV if the diameter of the aortic root or ascending aorta is ≥5.5 cm (Class I)
Intervention to repair or replace the aortic root (sinuses) or replace the ascending aorta is reasonable in asymptomatic patients with BAV if the diameter of the aortic root or ascending aorta is ≥5.0 cm and an additional risk factor for dissection is present (eg, family history of aortic dissection or aortic growth rate ≥0.5 cm per year) or if the patient is at low surgical risk and the surgery is performed by an experienced aortic surgical team in a center with established expertise in these procedures. (Class IIa)
Replacement of the ascending aorta is reasonable in patients with BAV undergoing AVR because of severe aortic stenosis or aortic regurgitation when the diameter of the ascending aorta is >4.5 cm. (Class IIa)
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Aortic regurgitation. Color Doppler echocardiogram.
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Aortic regurgitation. Doppler echocardiographic signals may be reviewed to evaluate the severity of disease.
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Aortic regurgitation. Two-dimensional (2D) color Doppler echocardiography.
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Aortic regurgitation. Aortic-root angiography shows regurgitation of contrast material into the left ventricle (LV).
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Aortic regurgitation. Chest radiograph in a patient with aortic dissection and acute aortic regurgitation shows a cardiac silhouette of essentially normal dimension.
Tables
LVESD (mm) |
LVEDD (mm) |
Dimensions |
Clinical Evaluation |
Echocardiogram |
< 45 |
< 60 |
Stable |
6-12 months |
12 months |
< 45 |
< 60 |
Increasing |
3 months |
3 months |
45-50 |
60-70 |
Stable |
6 months |
12 months |
45-50 |
60-70 |
Increasing |
3 months |
3 months |
50-55 |
70-75 |
Stable |
6 months |
6 months |
50-55 |
70-75 |
Increasing |
3 months |
3 months |
>55 |
>75 |
|
Surgery recommended |
|
Aortic valve replacement (AVR) indications Note: STS guidelines recommend “valve replacement or valve repair” |
AHA/ACC (2014) [4] |
ESC/EACTS (2012) [43] |
STS (2013) [9] |
Symptomatic severe AR |
Class I |
Class I |
Class I |
Asymptomatic chronic severe AR and left ventricular ejection fraction (LVEF) ≤50% |
Class I |
Class I |
Class I |
Severe AR when undergoing other cardiac surgery |
Class I |
Class I |
Class I |
Asymptomatic severe AR with normal LVEF (≥50%) but with severe LV dilation (LVESD >50mm) |
Class IIa-Reasonable |
Class IIa-Reasonable |
Class IIa-Reasonable |
Moderate AR when undergoing other cardiac surgery |
Class IIa-Reasonable |
Class IIb-Consider |
|
Asymptomatic severe AR and normal LVEF (≥50%) but with progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low |
Class IIb-Consider |
Class IIa-Reasonable |
Class IIb-Consider |
Not indicated for asymptomatic patients with mild, moderate, or severe AR and normal LV systolic function at rest when the degree of LV dilation is not moderate or severe |
Class III |
