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[Diagnosis and indication for aortic valve replacement in asymptomatic and symptomatic patients with aortic
L Mandinov1, P Kaufmann, O M Hess
1Inspital, Bern, Schweiz.
Insights
Chronic volume overload from aortic regurgitation can cause left ventricular remodeling. Early aortic valve replacement is crucial for symptomatic patients or those with reduced heart function, while asymptomatic patients require regular monitoring.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardiovascular Physiology
Context:
- Chronic volume overload, often due to aortic regurgitation, leads to left ventricular remodeling, including dilatation and eccentric hypertrophy.
- Despite significant regurgitation, patients may remain asymptomatic for years due to adaptive changes in left ventricular pressure-volume relationships.
Purpose:
- To outline the diagnostic criteria and optimal timing for aortic valve replacement in patients with severe aortic regurgitation.
- To differentiate management strategies for symptomatic versus asymptomatic patients based on left ventricular function and dimensions.
Summary:
- Symptomatic patients with severe aortic regurgitation require prompt valve replacement.
- Asymptomatic patients with preserved left ventricular function have a good prognosis but need regular monitoring for dysfunction, especially with significant left ventricular dilatation (end-diastolic diameter >70 mm, end-systolic diameter >50 mm).
- Valve replacement is indicated in asymptomatic patients with ejection fraction <50% or end-systolic diameter >55 mm.
Impact:
- Provides guidance for clinicians in managing severe aortic regurgitation, optimizing surgical timing to prevent irreversible myocardial damage.
- Highlights the importance of serial echocardiographic monitoring to detect subtle declines in left ventricular function and guide intervention.
Abstract:
Chronic volume overload is associated with dilatation and eccentric hypertrophy of the left ventricle (= ventricular remodeling). With the dilatation of the left ventricle and the shift of the pressure-volume-relationship to the right, the filling pressures can be kept normal despite severe regurgitation. Therefore, the patient with aortic regurgitation can remain asymptomatic over many years. Thus, the indication for aortic valve replacement in patients with severe aortic regurgitation is sometimes difficult and may lead to problems to choose the optimal time point for operation. As a general rule, symptomatic patients with severe aortic regurgitation should be operated as soon as possible. In asymptomatic patients with significant dilatation of the left ventricle and reduction of systolic pump function the therapy of choice is aortic valve replacement. Asymptomatic patients with normal left ventricular function have usually a good prognosis with a yearly mortality rate of approximately 0.04%. However, in the presence of significant dilatation of the left ventricle, i.e. enddiastolic chamber diameter more than 70 mm respectively endsystolic diameter more than 50 mm, patients have to be checked on a regular basis, i.e. in yearly intervals to detect left ventricular dysfunction in due time. According to the literature, asymptomatic patients with severe aortic regurgitation develop left ventricular dysfunction in a yearly rate of 4%. However, approximately 50% of all patients are even after 10 years asymptomatic. The indication for aortic valve replacement is given when the patient shows a deterioration of left ventricular function or becomes symptomatic. Valve replacement is also indicated in patients with an ejection fraction below 50% and/or endsytolic chamber diameter of more than 55 mm. Therapy of choice in symptomatic patients with severe aortic regurgitation is aortic valve replacement. In asymptomatic patients, operation depends on the degree of chamber dilatation respectively the severity of left ventricular dysfunction. In patients with severe aortic regurgitation but without clinical symptoms and moderate enlargement of the left ventricle regular check-ups in yearly intervals are indicated. In the presence of severe left ventricular dilatation check-ups should be performed on a half-year basis to prevent irreversible damage to the heart muscle.