Natural history and management of chronic aortic regurgitation in adults
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
In most patients with chronic aortic regurgitation (AR), the disease evolves in a slow and insidious manner with a very low morbidity during a long asymptomatic phase. While some patients with mild AR do not progress for decades, others exhibit progression of the regurgitant lesion with the gradual development of severe AR with subsequent left ventricular dilation, systolic dysfunction, and eventually heart failure (table 1). (See 'Natural history' below.)
The volume load that burdens the left ventricle in patients with chronic AR leads to a series of compensatory myocardial and circulatory adjustments that can be affected by pharmacologic therapy and reversed by valve replacement. Thus, the management of patients with this disorder requires an understanding of the natural history of the disease, the limited role of medical therapy, and the timing of surgery .
This topic will review the management and prognosis of chronic AR. The pathophysiology, major clinical features, and surgical treatment of chronic AR and issues related to acute AR in adults are discussed separately. (See "Clinical manifestations and diagnosis of chronic aortic regurgitation in adults" and "Acute aortic regurgitation in adults".)
Chronic aortic regurgitation (AR) generally evolves slowly with a long asymptomatic compensated phase with some patients developing worsening regurgitation that may progress to severe AR with left ventricular (LV) dilation, LV systolic dysfunction, and heart failure (table 1).
Data from case series of patients with chronic AR have been used to develop criteria to define compensated and decompensated phases of chronic severe AR (table 2A-B):
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- NATURAL HISTORY
- General approach
- - Clinical follow-up
- - Imaging
- Cardiovascular magnetic resonance
- Cardiac catheterization
- Bicuspid aortic valve and aortic disease
- Approach to treatment
- General management
- - Pharmacologic therapy
- - Endocarditis prophylaxis
- - Recommendations for physical activity and exercise
- Aortic valve surgery
- - Indications for aortic valve surgery
- - Preoperative evaluation
- - Choice of procedure
- - Investigational transcatheter alternative
- - Evidence
- For aortic valve surgery
- For investigational transcatheter aortic valve implantation
- SUMMARY AND RECOMMENDATIONS