Aortic insufficiency surgery indications

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 * Associate Editor-In-Chief: Mohammed A. Sbeih, M.D.[mailto:msbeih@perfuse.org]

Related Key Words and Synonyms: Aortic valve replacement.

Overview
Aortic valve replacement is indicated in patients with severe aortic insufficiency who are either symptomatic or those who have a left ventricular end-diastolic diameter >55 mm or 25 mm/m2 or an left ventricular ejection fraction <55%.

Indications for Surgery for Chronic Severe Aortic Insufficiency

 * Aortic valve replacement improves symptoms in symptomatic patients with severe aortic insufficiency.
 * In some studies, the left ventricular function (ejection fraction) also improved following AVR.
 * In severe aortic insufficiency, new onset of mild symptoms are also candidates for AVR. Surgery should not be delayed until the development of advanced symptoms as this may result in irreversible left ventricular dysfunction.
 * Patients who are symptomatic with NYHA Class IV heart fialure have poor outcomes following AVR with less likelihood of an improvement in left ventricular systolic function   . Following AVR, ventricular loading conditions may be improved and this may improve the subsequent management of left ventricular dysfunction.
 * Symptomatic patients even with mild to moderate left ventricular systolic dysfunction (ejection fraction 25%- 50%) should also undergo AVR.
 * The AHA/ACC guidelines recommends that patients with NYHA Class II and III symptoms should undergo valve replacement if :
 * 1) The symptoms and evidence of left ventricular dysfunction are of recent onset
 * 2) Intensive short-term therapy with vasodilators and diuretics results in symptomatic improvement
 * 3) Intravenous positive inotropic agents result in substantial improvement in hemodynamics or systolic function.


 * Aortic valve replacement/repair is not recommended in a truly asymptomatic patient with normal left ventricular function (left ventricular ejection fraction ≥50%) who does not have severe left ventricular dilatation because this would expose the patient to perioperative mortality risk of 4% against less than 0.2% mortality risk without surgery and other long-term complications of a prosthetic heart valve . In such patients 2006 AHA/ACC guidelines recommends :
 * Patients with mild chronic aortic insufficiency with normal left ventricular ejection fraction should undergo clinical evaluation yearly and echocardiography every two to three years.
 * Patients with severe chronic aortic insufficiency with normal left ventricular ejection fraction should be followed up based on ventricular dimensions:
 * 1) Patients with end-systolic ventricular dimension <45 mm and end-diastolic ventricular dimension <60 mm should undergo clinical evaluation every 6 to 12 months and echocardiography every 12 months. However, if the patient is not stable or if this is the initial study, the patient should be re-evaluated and echocardiography performed in 3 months.
 * 2) Patients with end-systolic ventricular dimensions of 45-50 mm and end-diastolic ventricular dimensions of 60-70 mm should undergo clinical evaluation every 6 months and echocardiography every 12 months. However, if the patient is not stable or this is the initial study, then the patient should be re-evaluated and echocardiography performed in 3 months.
 * 3) Patients with end-systolic ventricular dimension 50-55 mm and end-diastolic ventricular dimension 70-75 mm with normal hemodynamic response to exercise should undergo clinical evaluation every 6months and echocardiography every 6 months. However, if the patient is not stable or this is the initial study, then the patient should be re-evaluated and echocardiography performed in 3 months.


 * When interpreting the cutpoints of left ventricular dimensions, the body size of the patients should also be taken into consideration. Women or patients with small body size may not achieve ventricular dimensions mentioned above as these dimensions were established in men  . On the other hand, body surface area measures are considered in the assessment of left ventricular dimension, tend to mask the diagnosis of left ventricular enlargement, especially in patients who are overweight . Therefore patient's height and gender should be considered during interpretation of ventricular dimensions.

==ACC/AHA Guidelines- Indications for Aortic Valve Replacement/Repair in Chronic Aortic Insufficiency (DO NOT EDIT) == {{cquote|

Class I
1. AVR is indicated for symptomatic patients with severe AR irrespective of LV systolic function. (Level of Evidence: B)

2. AVR is indicated for asymptomatic patients with chronic severe aortic insufficiency and left ventricular systolic dysfunction (ejection fraction 50% or less) at rest. (Level of Evidence: B)

3. AVR is indicated for patients with chronic severe aortic insufficiency while undergoing coronary artery bypass graft(CABG) or surgery on the aorta or other heart valves. (Level of Evidence: C)

Class IIa
1. AVR is reasonable for asymptomatic patients with severe aortic insufficiency with normal left ventricular systolic function (ejection fraction greater than 50%) but with severe left ventricular dilatation (end-diastolic dimension greater than 75 mm or end-systolic dimension greater than 55 mm). (Level of Evidence: B)

Class IIb
1. AVR may be considered in patients with moderate aortic insufficiency while undergoing surgery on the ascending aorta. (Level of Evidence: C)

2. AVR may be considered in patients with moderate aortic insufficiency while undergoing CABG. (Level of Evidence: C)

3. AVR may be considered for asymptomatic patients with severe aortic insufficiency and normal left ventricular systolic function at rest (ejection fraction greater than 50%) when the degree of left ventricular dilatation exceeds an end-diastolic dimension of 70 mm or end-systolic dimension of 50 mm, when there is evidence of progressive left ventricular dilatation, declining exercise tolerance, or abnormal hemodynamic responses to exercise. (Level of Evidence: C)

Class III
1. AVR is not indicated for asymptomatic patients with mild, moderate, or severe aortic insufficiency and normal left ventricular systolic function at rest (ejection fraction greater than 50%) when the degree of dilatation is not moderate or severe (end-diastolic dimension less than 70 mm, end-systolic dimension less than 50 mm). (Level of Evidence: B)}}