Skip to main content

Timing of Surgical Intervention for Aortic Regurgitation

Current Treatment Options in Cardiovascular Medicine volume 18, Article number: 63 (2016) Cite this article

Opinion statement

Aortic regurgitation is a frequently encountered condition, in which traditional measurements of severity have proven to be of limited value in identifying those who would be best served by aortic valve replacement. Novel methods of assessing severity are vital, particularly as an entirely new paradigm of aortic regurgitation has surfaced, with the advent of transcatheter aortic valve replacement (TAVR), and the adverse events that are being observed with varying degrees of aortic regurgitation. With that in mind, a comprehensive assessment of aortic regurgitation should now include indexed left ventricular systolic volumes and a comprehensive assessment of right ventricular function, in addition to the quantitative measures that are currently recommended. Cardiac MRI also provides valuable information and should be strongly considered, particularly in challenging cases. The incremental value of additional echocardiographic parameters such as strain imaging, speckle tracking imaging, and tissue Doppler imaging remains unclear, and evidence for their utility is not, as yet, compelling. However, the field of aortic regurgitation assessment has been reinvigorated by the prevalence of paravalvular regurgitation post-TAVR, and many of the abovementioned parameters may need to be re-visited so that we can more accurately determine prognosis and risk stratify patients in a more reliable and evidence-based manner.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Singh JP, Evans JC, Levy D, Larson MG, Freed LA, Fuller DL, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol. 1999;83(6):897–902.

    CAS  PubMed  Article  Google Scholar 

  2. Dujardin KS, Enriquez-Sarano M, Schaff HV, Bailey KR, Seward JB, Tajik AJ. Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study. Circulation. 1999;99(14):1851–7.

    CAS  PubMed  Article  Google Scholar 

  3. Lebowitz NE, Bella JN, Roman MJ, Liu JE, Fishman DP, Paranicas M, et al. Prevalence and correlates of aortic regurgitation in American Indians: the Strong Heart Study. J Am Coll Cardiol. 2000;36(2):461–7.

    CAS  PubMed  Article  Google Scholar 

  4. Keane MG, Pyeritz RE. Medical management of Marfan syndrome. Circulation. 2008;117(21):2802–13.

    PubMed  Article  Google Scholar 

  5. Ortiz JT, Shin DD, Rajamannan NM. Approach to the patient with bicuspid aortic valve and ascending aorta aneurysm. Curr Treat Options Cardiovasc Med. 2006;8(6):461–7.

    PubMed  Article  Google Scholar 

  6. Seckeler MD, Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clin Epidemiol. 2011;3:67–84.

    PubMed  PubMed Central  Article  Google Scholar 

  7. Sinning JM, Vasa-Nicotera M, Chin D, Hammerstingl C, Ghanem A, Bence J, et al. Evaluation and management of paravalvular aortic regurgitation after transcatheter aortic valve replacement. J Am Coll Cardiol. 2013;62(1):11–20.

    PubMed  Article  Google Scholar 

  8. Rigolin VH, Bonow RO. Hemodynamic characteristics and progression to heart failure in regurgitant lesions. Heart Fail Clin. 2006;2(4):453–60.

    PubMed  Article  Google Scholar 

  9. Maganti K, Rigolin VH, Sarano ME, Bonow RO. Valvular heart disease: diagnosis and management. Mayo Clin Proc. 2010;85(5):483–500.

    PubMed  PubMed Central  Article  Google Scholar 

  10. Carabello BA. Aortic valve disease. In: Willerson JT, Wellens HJJ, Cohn JN, Holmes DR, editors. Cardiovascular medicine. London: Springer London; 2007. p. 381–92.

    Chapter  Google Scholar 

  11. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation. 2005;112(1):125–34.

    PubMed  Article  Google Scholar 

  12. Maurer G. Aortic regurgitation. Heart. 2006;92(7):994–1000.

    PubMed  PubMed Central  Article  Google Scholar 

  13. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin 3rd JP, Guyton RA, 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;63(22):e57–e185.

    PubMed  Article  Google Scholar 

  14. Bonow RO, Lakatos E, Maron BJ, Epstein SE. Serial long-term assessment of the natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function. Circulation. 1991;84(4):1625–35.

    CAS  PubMed  Article  Google Scholar 

  15. Borer JS, Hochreiter C, Herrold EM, Supino P, Aschermann M, Wencker D, et al. Prediction of indications for valve replacement among asymptomatic or minimally symptomatic patients with chronic aortic regurgitation and normal left ventricular performance. Circulation. 1998;97(6):525–34.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  16. Cape EG, Yoganathan AP, Weyman AE, Levine RA. Adjacent solid boundaries alter the size of regurgitant jets on Doppler color flow maps. J Am Coll Cardiol. 1991;17(5):1094–102.

    CAS  PubMed  Article  Google Scholar 

  17. Griffin BP, Flachskampf FA, Siu S, Weyman AE, Thomas JD. The effects of regurgitant orifice size, chamber compliance, and systemic vascular resistance on aortic regurgitant velocity slope and pressure half-time. Am Heart J. 1991;122(4 Pt 1):1049–56.

    CAS  PubMed  Article  Google Scholar 

  18. Detaint D, Messika-Zeitoun D, Maalouf J, Tribouilloy C, Mahoney DW, Tajik AJ, et al. Quantitative echocardiographic determinants of clinical outcome in asymptomatic patients with aortic regurgitation: a prospective study. JACC Cardiovasc Imaging. 2008;1(1):1–11.

    PubMed  Article  Google Scholar 

  19. Taniguchi K, Sawa Y. Contemporary reviews by surgeon: timing of operation for chronic aortic regurgitation. Gen Thorac Cardiovasc Surg. 2012;60(11):735–43.

    PubMed  Article  Google Scholar 

  20. Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16(7):777–802.

    PubMed  Article  Google Scholar 

  21. Cho SH, Byun CS, Kim KW, Chang BC, Yoo KJ, Lee S. Preoperative indexed left ventricular dimensions to predict early recovery of left ventricular function after aortic valve replacement for chronic aortic regurgitation. Circ J. 2010;74(11):2340–5. This paper illustrates the importance of simple measures to improve prognostic value by traditional echocardiographic imaging techniques by indexing measurements to body surface area.

    PubMed  Article  Google Scholar 

  22. Sambola A, Tornos P, Ferreira-Gonzalez I, Evangelista A. Prognostic value of preoperative indexed end-systolic left ventricle diameter in the outcome after surgery in patients with chronic aortic regurgitation. Am Heart J. 2008;155(6):1114–20.

    PubMed  Article  Google Scholar 

  23. Brown ML, Schaff HV, Suri RM, Li Z, Sundt TM, Dearani JA, et al. Indexed left ventricular dimensions best predict survival after aortic valve replacement in patients with aortic valve regurgitation. Ann Thorac Surg. 2009;87(4):1170–5. discussion 5-6.

    PubMed  Article  Google Scholar 

  24. Abraham TP, Nishimura RA. Myocardial strain: can we finally measure contractility? J Am Coll Cardiol. 2001;37(3):731–4.

    CAS  PubMed  Article  Google Scholar 

  25. Haugaa KH, Grenne BL, Eek CH, Ersboll M, Valeur N, Svendsen JH, et al. Strain echocardiography improves risk prediction of ventricular arrhythmias after myocardial infarction. JACC Cardiovasc Imaging. 2013;6(8):841–50.

    PubMed  Article  Google Scholar 

  26. Kusunose K, Agarwal S, Marwick TH, Griffin BP, Popovic ZB. Decision making in asymptomatic aortic regurgitation in the era of guidelines: incremental values of resting and exercise cardiac dysfunction. Circ Cardiovasc Imaging. 2014;7(2):352–62. A novel study demonstrating utility of exercise echocardiography in selecting patients that may benefit from earlier surgical intervention for chronic aortic insufficiency.

    PubMed  Article  Google Scholar 

  27. Grant AD, Smedira NG, Starling RC, Marwick TH. Independent and incremental role of quantitative right ventricular evaluation for the prediction of right ventricular failure after left ventricular assist device implantation. J Am Coll Cardiol. 2012;60(6):521–8.

    PubMed  Article  Google Scholar 

  28. Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure. Circulation. 2008;117(13):1717–31.

    PubMed  Article  Google Scholar 

  29. Lim ST, Marcovitz P, Pica M, O’Neill W, Goldstein J. Right ventricular performance at rest and during stress with chronic proximal occlusion of the right coronary artery. Am J Cardiol. 2003;92(10):1203–6.

    PubMed  Article  Google Scholar 

  30. Ho CY, Solomon SD. A clinician’s guide to tissue Doppler imaging. Circulation. 2006;113(10):e396–8.

    PubMed  Article  Google Scholar 

  31. Andersen NH. Subclinical left ventricular dysfunction in hypertension and diabetes assessed by tissue Doppler imaging. Dan Med Bull. 2010;57(6):B4150.

    Google Scholar 

  32. Suran D, Sinkovic A, Naji F. Tissue Doppler imaging is a sensitive echocardiographic technique to detect subclinical systolic and diastolic dysfunction of both ventricles in type 1 diabetes mellitus. BMC Cardiovasc Disord. 2016;16:72.

    PubMed  PubMed Central  Article  Google Scholar 

  33. Weidemann F, Strotmann JM. Detection of subclinical LV dysfunction by tissue Doppler imaging. Eur Heart J. 2006;27(15):1771–2.

    PubMed  Article  Google Scholar 

  34. Vinereanu D, Ionescu AA, Fraser AG. Assessment of left ventricular long axis contraction can detect early myocardial dysfunction in asymptomatic patients with severe aortic regurgitation. Heart. 2001;85(1):30–6.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  35. Tayyareci Y, Yildirimturk O, Aytekin V, Demiroglu IC, Aytekin S, Tayyareci Y, et al. Subclinical left ventricular dysfunction in asymptomatic severe aortic regurgitation patients with normal ejection fraction: a combined tissue Doppler and velocity vector imaging study. Echocardiography. 2010;27(3):260–8. An important study revealing reliable use of tissue Doppler imaging for detection of early subclinical ventricular dysfunction in patients with asymptomatic severe aortic regurgitation.

    PubMed  Article  Google Scholar 

  36. Zoroufian A DH, Rezvanfard M, Sahebjam M, Sadeghian H, Tokaldany ML. Subclinical myocardial deformation abnormalities in asymptomatic patients with moderate to severe aortic regurgitation: a combined tissue Doppler and strain rate imaging study. Arch Cardiovasc Imaging. 2013;10.5812/acvi.11105.

  37. Geyer H, Caracciolo G, Abe H, Wilansky S, Carerj S, Gentile F, et al. Assessment of myocardial mechanics using speckle tracking echocardiography: fundamentals and clinical applications. J Am Soc Echocardiogr. 2010;23(4):351–69. quiz 453-5.

    PubMed  Article  Google Scholar 

  38. Olsen NT, Sogaard P, Larsson HB, Goetze JP, Jons C, Mogelvang R, et al. Speckle-tracking echocardiography for predicting outcome in chronic aortic regurgitation during conservative management and after surgery. JACC Cardiovasc Imaging. 2011;4(3):223–30. A study that demonstrated early detection of LV dysfunction using speckle-tracking echocardiography with severe aortic insufficiency. Strain patterns in this study were associated with disease progression in both conservative and surgical cohorts.

    PubMed  Article  Google Scholar 

  39. Hein S, Arnon E, Kostin S, Schonburg M, Elsasser A, Polyakova V, et al. Progression from compensated hypertrophy to failure in the pressure-overloaded human heart: structural deterioration and compensatory mechanisms. Circulation. 2003;107(7):984–91.

    PubMed  Article  Google Scholar 

  40. Heymans S, Schroen B, Vermeersch P, Milting H, Gao F, Kassner A, et al. Increased cardiac expression of tissue inhibitor of metalloproteinase-1 and tissue inhibitor of metalloproteinase-2 is related to cardiac fibrosis and dysfunction in the chronic pressure-overloaded human heart. Circulation. 2005;112(8):1136–44.

    CAS  PubMed  Article  Google Scholar 

  41. Krayenbuehl HP, Hess OM, Monrad ES, Schneider J, Mall G, Turina M. Left ventricular myocardial structure in aortic valve disease before, intermediate, and late after aortic valve replacement. Circulation. 1989;79(4):744–55.

    CAS  PubMed  Article  Google Scholar 

  42. Villari B, Vassalli G, Monrad ES, Chiariello M, Turina M, Hess OM. Normalization of diastolic dysfunction in aortic stenosis late after valve replacement. Circulation. 1995;91(9):2353–8.

    CAS  PubMed  Article  Google Scholar 

  43. Azevedo CF, Nigri M, Higuchi ML, Pomerantzeff PM, Spina GS, Sampaio RO, et al. Prognostic significance of myocardial fibrosis quantification by histopathology and magnetic resonance imaging in patients with severe aortic valve disease. J Am Coll Cardiol. 2010;56(4):278–87. This paper addresses the possible yield of cardiac MRI in detecting subclinical pathologic changes and therefore may help risk stratify those patients who may benefit from earlier surgical intervention.

    PubMed  Article  Google Scholar 

Download references

Author information

Affiliations

  1. Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA

    Brett Hiendlmayr MD, Joseph Nakda MD, Ossama Elsaid MD & Aidan Flynn MD, PhD

  2. University of Connecticut School of Medicine, Farmington, CT, 06030, USA

    Xuan Wang MD & Aidan Flynn MD, PhD

Authors
  1. Brett Hiendlmayr MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joseph Nakda MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ossama Elsaid MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Xuan Wang MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Aidan Flynn MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Aidan Flynn MD, PhD.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Valvular Heart Disease

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hiendlmayr, B., Nakda, J., Elsaid, O. et al. Timing of Surgical Intervention for Aortic Regurgitation. Curr Treat Options Cardio Med 18, 63 (2016). https://doi.org/10.1007/s11936-016-0485-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11936-016-0485-3

Keywords

  • Aortic regurgitation
  • Surgery
  • Severity
  • Timing
  • TAVR
  • Echocardiography