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Aortic Regurgitation Surgical Timing
Patrick T. O’Gara, MD
Brigham and Women’s Hospital
Harvard Medical School
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Aortic Regurgitation Etiology
Valve
• BAV Disease
• Rheumatic
• IE
• Myxomatous
• Trauma
• Miscellaneous
Root
• CT Disorder
• Dissection
• IE
• Aortitis
• HTN
• Miscellaneous
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Acute Severe AR
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Average hospital mortality: 8.8%
• Low volume centers: 13.0%
• High volume centers: 6.0%
Data from national Medicare database 1994-1999
684 hospitals
142,488 AVRs
Medicare data
0
20
40
60
80
100
0 1 2 3 4 5Time (years)
100
80
60
40
20
0 0 2 4 6 8 10
Aliv
e, A
sym
pto
matic
with N
orm
al LV
Function (
%)
Asymptomatic with normal LV function
Aortic Regurgitation Natural History
1 3 5 7 9 11
Bonow et al. Circulation 1991;84:1625-1635
Tornos et al. Am Heart J 1995;130:333-339
Borer et al. Circulation 1998;97:525-534
64%
70%
54%
n 104 101 104
Annual risk 3.8% 3.1% 6.2%
Endpoints:
Symptoms 19 8 28
Asymp LVD 4 6 7 30% of endpoints occur
before onset of symptoms Death 2 0 4
• •
• • • •
Total 25 14 39
Bonow, J Am Coll Cardiol 2013;61:693-701
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Severe AR: TTE Criteria
• Color jet width > 60%
• Vena contracta > 6 mm
• T1/2 AR CW < 200 msec
• TVI flow reversal (SSN): 13-15 cm
• RV > 60 mL
• ERO > 30 mm2
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Aortic Regurgitation Survival and Function after AVR
Prognostic Factors
• Severity of pre-operative symptoms
• Severity of LV dysfunction
• Duration of LV dysfunction
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Average hospital mortality: 8.8%
• Low volume centers: 13.0%
• High volume centers: 6.0%
Data from national Medicare database 1994-1999
684 hospitals
142,488 AVRs
Medicare data
0
20
40
60
80
100
0 1 2 3 4 5Time (years)
100
80
60
40
20
0 0 2 4 6 8 10
Event-
Fre
e S
urv
ival
(perc
ent)
Aortic Regurgitation Cardiac Events Based on Severity of AR
1 3 5 7 9 11
66%
79%
37%
Mild
Moderate
Severe
Mild AR
Moderate AR
Severe AR
<30 <10
30-59 11-30
≥60 ≥30
RVol (ml) ERO (mm2)
from Detaint et al. J Am Coll Cardiol Img 2008;1:1-11
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BNP and Outcome in Aortic Regurgitation
Pizarro et al, J Am Coll Cardiol 2011;58:1701-1714
0
20
40
60
80
100
0 1 2 3 4
100
80
60
40
20
0
Event-
Fre
e S
urv
ival (%
)
Time (years)
0 1 2 3 4 5
BNP <130 pg/ml
p<0.001 BNP ≥130 pg/ml
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BNP OR 6.9 p=0.0001
ERO OR 3.4 p=0.001
LVESD OR 4.3 p=0.01
LVEDD OR 2.1 p=0.09
Multivariate analysis:
Predictors of cardiac events
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Aortic Regurgitation: Medical Therapy
Recommendations COR LOE
Treatment of hypertension (systolic BP >140 mm
Hg) is recommended in patients with chronic AR
(stages B and C), preferably with dihydropyridine
calcium channel blockers or angiotensin-
converting enzyme (ACE) inhibitors/angiotensin-
receptor blockers (ARBs)
I B
Medical therapy with ACE inhibitors/ARBs and
beta blockers is reasonable in patients with
severe AR who have symptoms and/or LV
dysfunction (stages C2 and D) when surgery is
not performed because of comorbidities
IIa B
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Recommendations COR LOE
AVR is indicated for symptomatic patients with
severe AR regardless of LV systolic function
(stage D) I B
AVR is indicated for asymptomatic patients with
chronic severe AR and LV systolic dysfunction
(LVEF <50%) (stage C2) I B
AVR is indicated for patients with severe AR (stage
C or D) who are undergoing other cardiac surgery I C
Aortic Regurgitation: Intervention
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Recommendations COR LOE
AVR is reasonable for asymptomatic patients
with severe AR with normal LV systolic
function (LVEF 50%), but severe LV dilation
(stage C2, LVESD >50 mm)
IIa B
AVR is reasonable in patients with moderate AR
(stage B) who are undergoing other cardiac
surgery
IIa C
AVR may be considered for asymptomatic
patients with severe AR and normal LV systolic
function (stage C1, LVEF ≥50%) but severe LV
dilation (LVEDD >65 mm) if surgical risk is low*
IIb C
Aortic Regurgitation: Intervention
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Aortic Regurgitation Long-Term Survival After AVR
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16
Su
rviv
al
(pe
rce
nt)
Group A n=60
Group B n=110
p<0.01
Time (months)
Tornos et al J Am Coll Cardiol 2006;26:1309-1313
Guidelines +
Guidelines -
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Pre-AVR Post-AVR
LV LV
LA
LA
Aortic
valve
Prosthetic
valve
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Survival After AVR Pre-Operative LV Function
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20
P < 0.001
Chaliki HP et al. Circulation 2002; 106:2687-93.
Years
Su
rviv
al
(%) EF > 0.50
EF < 0.35
EF 0.35-0.50
Peri-op mortality
Low EF 14%
Med EF 6.7%
Nml EF 3.7%
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Kamath A R et al. Circulation 2009;120:S134-S138
AVR with EF < 0.35
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Interstitial Fibrosis Effect of AVR
Villari B et al. Circulation 2009;120:2386-2392
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BAV
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Keane, M. G. et al. Circulation 2000;102:III-35-III-39
Measurement of Aortic Root
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Aortic Dimensions Bicuspid vs. Tricuspid Aortic Valve
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
Sinus STJ Asc Ao
BAV
TRI
P < 0.01
P < 0.001
P < 0.001
Keane MG et al. Circulation 2000; 102 [suppl III]: III-35-III-39.
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BAV Aortopathy
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Cardiac MRI BAV Disease
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Bicuspid Aortic Valve and Aortopathy:
Intervention Recommendations COR LOE
Operative intervention to repair the aortic sinuses or
replace the ascending aorta is indicated in patients
with a bicuspid aortic valve if the diameter of the
aortic sinuses or ascending aorta is greater than
5.5 cm
I B
Operative intervention to repair the aortic sinuses or
replace the ascending aorta is reasonable in patients
with bicuspid aortic valves if the diameter of the
aortic sinuses or ascending aorta is greater than
5.0 cm and a risk factor for dissection is present
(family history of aortic dissection or if the rate of
increase in diameter is ≥0.5 cm per year)
IIa C
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Bicuspid Aortic Valve and Aortopathy:
Intervention
Recommendations COR LOE
Replacement of the ascending aorta is reasonable
in patients with a bicuspid aortic valve who are
undergoing aortic valve surgery because of
severe AS or AR (Sections 3.4 and 4.4) if the
diameter of the ascending aorta is greater than
4.5 cm
IIa C
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Aortic Regurgitation Concluding Thoughts
• Medical therapy should focus on BP
• Etiology of AR may drive timing of surgery
• LV size thresholds for surgery have decreased
over time
• AVR can be considered in selected patients with
severe LV dysfunction (EF < 0.35)
• Aortic root size criteria have also changed for
patients with BAV disease and aortopathy
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80
60
40
20
0
BN
P (
pg/m
L)
LV Mass Index (g/m2)
50 75 100 125 150 175 200
BNP correlates with:
r p value
LVMi 0.77 <0.001
LVEDVi 0.73 0.001
LVESVi 0.69 0.002
Age 0.53 0.01
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Average hospital mortality: 8.8%
• Low volume centers: 13.0%
• High volume centers: 6.0%
Data from national Medicare database 1994-1999
684 hospitals
142,488 AVRs
Medicare data
0
20
40
60
80
100
0 1 2 3 4 5Time (years)
100
80
60
40
20
0 0 2 4 6 8 10
Surv
ival (
perc
ent)
Aortic Regurgitation Long-Term Survival After AVR
12
Group A
n=60
Tornos et al J Am Coll Cardiol 2006;26:1309-1313
p<0.01
14 16
Group B
n=110
Guidelines +
Guidelines -
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0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11
As
ym
pto
ma
tic
wit
h N
orm
al
LV
Fu
nc
tio
n (
pe
rce
nt)
58%
Bonow R et al. Circulation 1991; 84:1625-35
Borer J et al. Circulation 1998; 97:525-34
Time (years)
n 104 104
Annual Risk 3.8% 6.2%
45%
25% of endpoints occur
before onset of symptoms
Endpoints:
Symptoms 19 28
Asymp LVD 4 7
Death 2 4
Aortic Regurgitation Asymptomatic Patients with Normal
LV Function
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Asymptomatic AR with Normal LV Function
Bonow, Circulation 1984,1991
Siemienczuk, Ann Intern Med 1989
Tornos, Am Heart J 1995
Borer, Circulation 1998
Tarasoutchi, J Am Coll Cardiol 2003
Factors predictive of symptoms and /or LV dysfunction:
• LV end-systolic dimension/volume
• LV end-diastolic dimension/volume
• LV ejection fraction with exercise
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Indications for Aortic Valve Replacement for Chronic Aortic Regurgitation
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• Symptomatic patients
• LV systolic dysfunction
• Patients undergoing CABG
class I
class I
class I
Indications for valve replacement
Aortic regurgitation
class I
class I
class I
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• Symptomatic patients
• LV systolic dysfunction
• Patients undergoing CABG
• Severe LV dilatation
LVSD >50 mm
class I
class I
class I
Indications for valve replacement
Aortic regurgitation
class IIa
class I
class I
class I
class IIa
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• Symptomatic patients
• LV systolic dysfunction
• Patients undergoing CABG
• Severe LV dilatation
• Progressive LV dilatation,
low risk for surgery
LVSD >50 mm
class I
class I
class I
Indications for valve replacement
Aortic regurgitation
class IIa
class IIb
class I
class I
class I
class IIa
class IIa
LVDD >70 mm LVDD >65 mm
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Indications for Surgery
Valve Aorta
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BAV Disease
Fazel SS et al. J Thorac Cardiovasc Surg 2008; 135: 901-7
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Aortic Regurgitation
Cardiac Events Based on AR Severity
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10
Detaint et al. J Am Coll Cardiol Img 2008;1:1-11
Mild
Eve
nt-
Fre
e S
urv
iva
l
(perc
en
t)
Time (years)
Moderate 79%
66%
37%
Severe
Mild AR
Moderate AR
Severe AR
Rvol ERO
< 30 < 10
30-59 11-30
≥ 60 ≥ 30
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Aortic Regurgitation Survival After Aortic Valve Replacement
0
20
40
60
80
100
0 1 2 3 4
Su
rviv
al
(pe
rce
nt)
Forman et al, Am J Cardiol 1980;45:1120-1125
LVEF > 50%
LVEF < 50%
p<0.02
Time (years)