What are the guideline sources, guidelines and references for Aortic regurgitation ?
Guideline sources The following summarized guidelines for the evaluation and management of aortic regurgitation are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ACC 2021), the European Society of Cardiology (ESC/EACTS 2021), and the Society of Thoracic Surgeons (STS 2013). 1 2 3 4 5 6 6 7 Definition AR, also known as aortic insufficiency, is a structural heart disease characterized by diastolic flow of blood across the aortic valve, from the aorta into the left ventricle. 4 Epidemiology AR may be due to malfunction of the valve leaflets themselves, dilatation of the aortic root and annulus, or a combination of these factors. 6 Pathophysiology The prevalence of AR in the United States is estimated at 500 persons per 100,000 population. 5 Disease course https://web.pathway.md/diseases/rectZZjnwx7zhIc49 1/5 6/23/23, 2:40 AM Aortic regurgitation Pathway Chronic AR causes volume overload of the left ventricle, with ventricular dilation and systolic dysfunction, and clinical symptoms of HF. Acute AR results in acute HF, and can progress to cardiogenic shock due to an uncompensated decrease in effective stroke volume. 6 Prognosis and risk of recurrence Moderate or severe AR is associated with significant morbidity and mortality. In highly symptomatic patients (NYHA functional class 3-4), annual mortality rates of approximately 25% have been reported. 7 Calculator Calculator Calculator Cardiac Anesthesia Risk Evaluati NYHA functional classification f Revised C Guidelines 1. Diagnostic investigations Transthoracic echocardiogram: Obtain TTE for assessment of the cause and severity of regurgitation, LV size and systolic function, prognosis, and timing of valve intervention in patients with signs and symptoms of AR. B Obtain TTE for evaluation of the presence and severity of AR in patients with bicuspid aortic valve or with known dilation of the aortic sinuses or ascending aorta. B Further imaging: obtain cardiac magnetic resonance, TEE or perform cardiac catheterization for assessment of LV systolic function, systolic and diastolic volumes, aortic size and AR severity in patients with moderate or severe AR and suboptimal TTE images or a discrepancy between clinical and TTE findings. B 2. Medical management Pharmacotherapy: Initiate treatment of hypertension (systolic BP > 140 mmHg) in asymptomatic patients with chronic AR. B Initiate guideline-directed medical therapy for reduced LV ejection fraction with ACEIs, ARBs and/or sacubitril/valsartan in patients with severe AR having symptoms and/or LV systolic dysfunction (stages C2-D) but a prohibitive surgical risk. B 3. Surgical interventions https://web.pathway.md/diseases/rectZZjnwx7zhIc49 2/5 6/23/23, 2:40 AM Aortic regurgitation Pathway Indications for surgery, symptomatic patients: As per AHA/ACC 2021 guidelines, perform aortic valve surgery in symptomatic patients with severe AR (stage D) regardless of LV systolic function. B Show 3 more As per EACTS/ESC 2021 guidelines, perform surgery in symptomatic patients regardless of LV function. B Show 2 more As per STS 2013 guidelines, perform aortic valve replacement or repair in symptomatic patients with severe AR irrespective of LV systolic function. B Show 2 more Indications for surgery, asymptomatic patients: As per AHA/ACC 2021 guidelines, perform aortic valve surgery in asymptomatic patients with chronic severe AR and LV systolic dysfunction (LV ejection fraction 55%) (stage C2), if no other cause for systolic dysfunction is identified. B Show 2 more As per EACTS/ESC 2021 guidelines, perform surgery in asymptomatic patients with LV end- systolic diameter > 50 mm or LV end-systolic diameter > 25 mm/m 2 BSA (in patients with small body size) or resting LV ejection fraction 50%. B Show 3 more As per STS 2013 guidelines, perform aortic valve replacement or repair in asymptomatic patients with chronic severe AR and LV systolic dysfunction (LV ejection fraction 50%) at rest. B Show 3 more 4. Specific circumstances Pregnant patients (before pregnancy): obtain clinical evaluation and TTE in female patients with suspected valve disease contemplating pregnancy. B Show 5 more Pregnant patients (during pregnancy): obtain monitoring of pregnant patients with severe valve disease (stages C-D) in a tertiary-care center with a dedicated heart valve team of cardiologists, surgeons, anesthesiologists, and maternal-fetal medicine obstetricians with expertise in the management of high-risk cardiac conditions during pregnancy. B Show 5 more Patients with aortic stenosis: Perform aortic valve replacement in symptomatic patients with combined aortic stenosis and AR and a peak transvalvular jet velocity of at least 4.0 m/s or a mean transvalvular gradient of at least 40 mmHg. B Perform SAVR in asymptomatic patients with combined aortic stenosis and AR having a jet velocity of 4.0 m/s with an LV ejection fraction < 50%. B https://web.pathway.md/diseases/rectZZjnwx7zhIc49 3/5 6/23/23, 2:40 AM Aortic regurgitation Pathway Patients with coronary artery disease: perform CABG in patients with a primary indication for aortic/mitral valve surgery and coronary artery diameter stenosis 70%. B Show 3 more Patients undergoing non-cardiac surgery: obtain preoperative echocardiography in patients with clinically suspected moderate or greater degrees of valvular regurgitation undergoing non- cardiac surgery. B Show 2 more 5. Follow-up and surveillance Post-procedural follow-up: obtain baseline port-procedural TTE followed by periodic monitoring with TTE depending on type of intervention, length of time after intervention, ventricular function, and concurrent cardiac conditions in asymptomatic patients with any type of valve intervention. B Likelihood Ratios Pertinent positives The following findings increase the probability of aortic regurgitation in adults. -1 Finding LR+ Value Increased volume of murmur during transient arterial occlusion 8.4 (1.3-81) Presence of AR murmur (grade 3) 4.5 (1.6-14) Pertinent negatives The following findings decrease the probability of aortic regurgitation in adults. -1 Finding LR- Value Absence of AR murmur (grade < 1) 0.0 (0-0.9) volume of murmur during transient arterial occlusion not increased 0.3 (0.1-0.8) References 1. Catherine M Otto, Rick A Nishimura, Robert O Bonow et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg. 2021 Aug;162 2):e183-e353. Open 2. Svensson LG, Adams DH, Bonow RO et al. Aortic valve and ascending aorta guidelines for management and quality measures. Ann Thorac Surg. 2013 Jun;95 6 Suppl):S1 66. Open https://web.pathway.md/diseases/rectZZjnwx7zhIc49 4/5 6/23/23, 2:40 AM Aortic regurgitation Pathway 3. Alec Vahanian, Friedhelm Beyersdorf, Fabien Praz et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology ESC and the European Association for Cardio-Thoracic Surgery EACTS . Eur Heart J. 2021;ehab395. Open 4. Akinseye OA, Pathak A, Ibebuogu UN. Aortic Valve Regurgitation: A Comprehensive Review. Curr Probl Cardiol. 2018 Aug;43 8 315 334. Open 5. Nkomo VT, Gardin JM, Skelton TN et al. Burden of valvular heart diseases: a population-based study. Lancet. 2006 Sep 16;368 9540 1005 11. Open 6. Maurer G. Aortic regurgitation. Heart. 2006 Jul;92 7 994 1000. Open 7. Dujardin KS, Enriquez-Sarano M, Schaff HV et al. Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study. Circulation. 1999 Apr 13;99 14 1851 7. Open 8. Nishimura RA, Otto CM, Bonow RO et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10;129 23 2440 92. Open 9. Nishimura RA, Otto CM, Bonow RO et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jun 10;63 22):e57 185. Open 10. Nishimura RA, Otto CM, Bonow RO et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017 Jun 20;135 25):e1159-e1195. Open 11. Baumgartner H, Falk V, Bax JJ et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017 Sep 21;38 36 2739 2791. Open 12. Niteesh K. Choudhry, MD, Edward E. Etchells et al. Does This Patient Have Aortic Regurgitation?. JAMA. 1999;281 23 2231 2238. Open https://web.pathway.md/diseases/rectZZjnwx7zhIc49 5/5